JP2004302890A - Electronic clinical chart system - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To provide an electronic chart system in which medical data are mutually linked with nursing care data. <P>SOLUTION: This electronic clinical chart system has: servers 20 and 21 for managing patient master data, the medical data and the nursing care data; clients 28 to 44 and 60 to 63 for medical treatment which are linked with the servers 20 and 21 and arranged at medical facilities 12 and 15 to be able to input the medical data of the patient described in the master data; and clients 49 to 55, 55a to 55d and 68 to 70 for nursing care which are linked with the servers 20 and 21 and arranged at nursing and personal care facilities 13 and 17, and input the nursing care data of the patient. Both the clients 28 to 44 and 60 to 63 for medical treatment, and the clients 49 to 55, 55a to 55d and 68 to 70 for nursing care refer to the patient master data, medical data and nursing care data to be registered in the servers 20 and 21. <P>COPYRIGHT: (C)2005,JPO&NCIPI

Description

[0001]
TECHNICAL FIELD OF THE INVENTION
The present invention relates to an electronic medical record system in which medical data and nursing data cooperate with each other.
[0002]
[Prior art]
Conventional medical records were created on paper. Also, as shown in FIGS. 28 and 29, one chart is created for each patient for each facility (eg, medical facility, nursing facility), and a plurality of charts are created for the same patient. Had been created. Furthermore, in medical facilities, separate medical records were sometimes created for outpatients and inpatients.
The nursing homes include home care, home nursing, home rehabilitation, day care, day care rehabilitation, and dementia-responsive living co-care (group home), as well as a pharmacy, rehabilitation center, and acupuncture room. , And a kitchen, etc. In addition, as an entrance service business with nursing care insurance, there is a nursing home for the elderly (nursing care), each of which is an independent establishment. In addition, in the same building (care facility), there may be one or two or more establishments of home service establishments and entrance service establishments, and a patient's chart is created for each establishment, Separate medical records were created even when the same patient was involved in multiple establishments in the same building.
In recent years, with the development of computers and the like, electronic medical records have been created by computers (for example, see Patent Document 1).
Furthermore, care insurance has been enforced, care has been provided according to a care plan, and an electronic medical chart for care has been created (for example, see Patent Document 2).
[0003]
[Patent Document 1]
JP-A-11-342112
[Patent Document 2]
JP 2000-3391 A
[0004]
[Problems to be solved by the invention]
However, the conventional chart still has the following problems to be solved. Since the medical chart created on paper was created for each medical facility or each nursing care establishment, it could only be referenced by one facility or one establishment. If a patient receives a medical examination at multiple medical facilities and nursing homes, or receives services from independent establishments even within the same nursing home, a medical chart must be created for each patient. Regarding the master data (patient's personal information) such as the name, age, address, etc. that specify the individual patient, the same contents had to be entered in a plurality of medical records.
As in the inventions disclosed in Patent Literature 1 and Patent Literature 2, electronic medical records stored in a database have their medical data displayed on a data display device, but are viewed from other facilities. I couldn't do that. Moreover, the medical electronic medical chart and the nursing electronic medical chart do not cooperate with each other, and the master data of the patient must be registered for each facility.
[0005]
For example, a nursing care electronic medical chart written by a care worker in charge of home-based care and a medical electronic medical chart written by a healthcare professional at a medical facility cannot be referred to each other. If a patient visits a nursing home and a patient visits a medical facility in the afternoon, the healthcare professional must ask the caregiver about the patient's condition, write down the details, and then fill out the electronic medical record. The time and effort wasted. The same applies to business facilities such as medical facilities and nursing care facilities.
The present invention has been made in view of such circumstances, and it is an object of the present invention to provide an electronic medical record system in which medical data and nursing data are mutually linked.
[0006]
[Means for Solving the Problems]
An electronic medical record system according to the present invention that meets the above-described object is a server that manages master data for specifying a patient, medical data of the patient, and care data for the patient, and cooperates with the server, and is arranged in a medical facility and receives the master data. A medical client capable of inputting the described medical data of a patient, and nursing care that is arranged in a nursing facility in cooperation with a server and capable of inputting the nursing care data of the patient described in the master data. And the medical client and the nursing care client can refer to the master data, medical data, and nursing data of the patient registered in the server from both the medical client and the nursing care client.
[0007]
Thus, the input of the master data of the patient only needs to be performed once in either the medical facility or the nursing care facility, and the patient does not need to write the same information many times. Furthermore, information on patients (eg, medical treatment results, test results, medication, etc.) performed or observed in medical facilities and nursing care facilities can be provided by medical staff and caregivers from both medical clients and care clients, respectively. It is possible to refer.
For example, if a patient receives nursing care by a nursing staff in the morning and consults a medical facility in the afternoon, the nursing care staff may register patient information (for example, the state of the patient) on the server after the end of the nursing care. Healthcare professionals only need to look at the information to know the patient's morning status, and there is no need for the healthcare professional to ask the caregiver for the patient's morning information, and it is also necessary to duplicate that information in the chart. Is also gone.
[0008]
In the electronic medical record system according to the present invention, there may be a plurality of medical facilities provided with medical clients and / or care facilities provided with care clients. As a result, patient information can be shared between medical facilities and nursing facilities, and the patient does not have to always go to the same medical facility and the same nursing facility. For example, if a patient becomes ill outside his / her place of residence, such as a travel destination, if the medical facility has a medical client, even a physician who examines the patient for the first time can refer to the patient's information. Thus, it is possible to know the pre-existing symptoms and the like, and the doctor can perform an appropriate treatment. The same applies to nursing homes.
In the electronic medical record system according to the present invention, the server has a medical server in which medical data is stored, and a nursing server in which nursing data is stored. Alternatively, master data having the same contents may be stored separately. Thereby, since the medical server and the nursing care server are linked with the medical client and the nursing care client, respectively, it is easy to prevent leakage of the medical data and the nursing care data. In addition, since the same master data is stored in each server, it is only necessary to register at one of the facilities.
[0009]
In the electronic medical record system according to the present invention, each individual identification code for identifying an individual is registered in advance on the server for the medical staff of the medical facility and the caregiver of the nursing facility, and data can be input and referenced by the identification symbol. Range can be determined. As a result, the range that can be input and referred to is determined by the identification symbol, and leakage or rewriting of various data can be prevented.
In the electronic medical record system according to the present invention, the server may include a personal identification server in which an identification symbol is registered. Thereby, the server in which the identification symbol is registered is provided separately from the server that stores the medical data and the nursing care data, so that leakage and rewriting of various data are easily prevented, and the maintainability of each server is improved.
[0010]
BEST MODE FOR CARRYING OUT THE INVENTION
Next, embodiments of the present invention will be described with reference to the accompanying drawings to provide an understanding of the present invention.
Here, FIG. 1 is an explanatory diagram of a network of an electronic medical record system according to an embodiment of the present invention, FIG. 2 is an explanatory diagram of a server of the electronic medical record system, and FIGS. FIG. 4 is an explanatory diagram of a distribution information storage unit group of a medical server and a nursing care server of the medical chart system, FIG. 4 is an explanatory diagram of an electronic medical record of the electronic medical record system, and FIG. FIG. 6 is a flow chart of electronic medical record entry of the electronic medical record system, FIG. 7 is an explanatory view showing a screen transition of a client of the electronic medical record system, and FIG. 8 is a medical electronic medical record of the electronic medical record system. FIG. 9 is an explanatory view of a clinical test result screen, FIG. 10 is an explanatory view of a medical chart browser screen, FIG. 11 is an explanatory view of a thermometry list screen, and FIG. 12 is a blood glucose level list screen. , FIG. 13 is an explanatory view of a CAPD drainage table screen, FIG. 14 is an explanatory view of a medicine instruction input screen, FIG. 15 is an explanatory view of an injection instruction input screen, FIG. 16 is an explanatory view of a radiological examination instruction input screen, 17 is an explanatory view of a clinical test instruction input screen, FIG. 18 is an explanatory view of another instruction input screen, FIG. 19 is an explanatory view of a pattern instruction input screen, FIG. 20 is an explanatory view of a critical path input screen, and FIG. FIG. 22 is an explanatory view of a disease name input screen, FIG. 23 is an explanatory view of a temperature measurement result input screen, FIG. 24 is an explanatory view of a CAPD record input screen, FIG. 25 is an explanatory view of a blood sugar level input screen, FIG. Is a flowchart for referencing an electronic medical record of the electronic medical record system, and FIG. 27 is an explanatory diagram of a care electronic medical record screen of the electronic medical record system.
[0011]
An electronic medical record system 10 according to an embodiment of the present invention will be described with reference to FIGS.
As shown in FIG. 1, the electronic medical record system 10 has a plurality of, for example, two medical facilities 12, 15 and nursing facilities 13, 17, respectively. In the first building 11, there are a first medical facility 12 and a first care facility 13. In the second building 14 and the third building 16, there are a second medical facility 15 and a second care facility 17, respectively. Further, in the first building 11, at one or more of the first and second medical facilities 12, 15 and the first and second nursing care facilities 13, 17, a medical examination, nursing care, etc. are received. There is a server room 19 provided with a server group 18 composed of a plurality of servers for storing various data of a patient (for example, name, age, address, diagnosis result, examination result, hospitalization record, care record, etc.).
[0012]
Here, each facility will be described in detail with reference to FIG.
The first medical facility 12 includes a general reception desk, a plurality of medical departments (for example, six departments of internal medicine, cardiology, neurosurgery, respiratory department, pediatrics, and rehabilitation department), a plurality of examination rooms (here, blood Inspection, urinalysis, X-ray (X-ray) examination, ultrasound examination, CT (computed tomography) examination, arteriosclerosis measurement (PWV) examination, seven kinds of bone density examination), various treatments (for example, height measurement, weight measurement) , Blood pressure measurement, injection, etc.), a treatment room, pharmacy, and accounting. Further, the first medical facility 12 includes a hospital ward having a nurse's office and a plurality of hospital rooms, a rehabilitation center, an acupuncture room, a kitchen, and a server room 19.
[0013]
In addition, the first care facility 13 includes a plurality of, for example, eleven service providing establishments (in the present embodiment, visiting nursing, visiting care, outpatient nursing, visiting rehabilitation, outpatient rehabilitation, dementia-response type living joint nursing care (hereinafter, referred to as “dementia coping care”). Group home), nursing home for the elderly, rehabilitation center, acupuncture room, pharmacy, kitchen), and has a nursing care staff station for nursing care staff engaged in on-site nursing care, a visiting nursing reception desk, a nursing home, and a kitchen. are doing. In addition, the first nursing home 13 has a nursing home and a room for the nursing care staff for the in-home caregivers (for example, residents of a dementia-compatible living care home, a nursing home for the aged), and furthermore, a nursing home care facility. There is a nursing home and a place for attendants.
In addition, the second medical facility 15 has a reception, one medical examination department (for example, internal medicine), one examination room (for example, X-ray examination), a pharmacy, and an accounting. The second nursing care facility 17 has respective reception desks and places for visiting care, visiting rehabilitation, and visiting nursing.
Note that, in the medical facility and the nursing facility, the respective medical departments and offices are not limited, and may be in any form.
[0014]
The server group 18 in the server room 19 includes a medical server 20 for storing medical data of patients in the first and second medical facilities 12 and 15, and nursing care data of patients in the first and second nursing facilities 13 and 17. , And further, the medical server 20 and the nursing care server 21 have a medical backup server 22 and a nursing care backup server 23 for backing up data stored in the respective servers. have. Further, the server group 18 includes a user identification server (an example of a personal identification server) 24 in which individual identification codes for identifying the medical staff of the medical facilities 12 and 15 and the caregivers of the care facilities 13 and 17 are registered. have. These servers 20 to 24 are linked via a hub 24a. The hub 24a is linked to the hub 25 for the first building. Further, the hub 25 cooperates with the hub 26 of the medical facility 12, and the hub 26 is connected to a medical client shown below, which is configured by a personal computer (hereinafter, referred to as a PC). Note that the medical server 20, the nursing care server 21, and the user identification server 24 include a backup storage device (for example, a magnetic tape or the like) not shown.
[0015]
The hub 26 installed in the first medical facility 12 has a reception client 28, a medical examination group 28 a, a test group 28 b, a treatment room client 42, a pharmacy client 43, and a nurse's station in the hospital ward. The provided hospital ward client 44 is connected.
Here, as shown in FIG. 5, the medical department client group 28a includes a medical client 29, a cardiology client 30, a neurosurgery client 31, a respiratory client 32, a pediatric client 33, and It has a rehabilitation department client 34. The test client group 28b includes a blood test client 35, a urine test client 36, an X-ray test client 37, an ultrasonic test client 38, a CT test client 39, a PWV test client 40, a bone density test. Client 41. Here, each of the medical clients 28 to 44 may be a single PC or a plurality of PCs (the same applies to the following clients).
[0016]
The hub 25 cooperates with a hub 46 provided in the first nursing care facility 13 and is connected to a nursing care client including the following PCs. Here, the hub 46 includes a nursing care client for each business establishment, that is, a visiting nursing care client 49, a visiting care nursing client 50, an outpatient nursing care client 51, a visiting rehabilitation client 52, an outpatient rehabilitation client 53, A group home client 54, a care for the elder health care client 55, a rehabilitation center client 55a, an acupuncture client 55b, a pharmacy client 55c, and a kitchen client 55d are connected.
[0017]
In addition, the hub 24a cooperates with a hub 56 that cooperates with the second and third buildings 14 and 16. The hub 56 is connected to a hub 59 installed in the second building 14 via a router 57 installed in the first building 11 and a router 58 installed in the second building 14. It is connected. Further, a reception client 60, a medical client 61, an X-ray examination client 62, and a pharmacy client 63, which are medical clients, are connected to the hub 59.
The hub 56 is connected to a hub 67 installed in the third building 16 via a router 65 for the third building installed in the first building 11 and a router 66 installed in the third building 16. Is connected to Further, the hub 67 is connected to a visiting care client 68, a visiting care client 69, and a visiting rehabilitation client 70, which are care clients.
[0018]
Here, the transfer rates of the hubs 24a, 25, and 56 are 1 Gbps (giga bit per second), and the transfer rates of the hubs 26, 46, 59, and 67 are 100 Mbps (mega bit per second) (in the figure). A hub of 1 Gbps is denoted as HUBa, and a hub of 100 Mbps is denoted as HUBb.) The communication speeds between the routers 57 and 58 and the routers 65 and 66 connecting the first building 11 to the second and third buildings 14 and 16 are respectively 128 kbps (kilo bit per second). You are using a line. In addition, the transfer speed may be increased by linking the respective routers of the first building and the second and third buildings with an optical cable, and furthermore, the Internet network may be used. However, when using the Internet network, a security system that prevents access from outside the electronic medical record system is required.
[0019]
Here, the medical server 20, the nursing care server 21, and the user identification server 24 of the server group 18 will be described with reference to FIGS. 2, 3A and 3B, respectively.
The server for user identification 24 includes the names, occupations, affiliations, ranks, dates of joining, etc. of all the staff working in the first and second medical facilities 12, 15 and the first and second nursing facilities 13, 17. Has a staff data storage unit 71 in which personal information of the user is registered. Here, the occupation of the staff is a doctor, a nurse, a physiotherapist, or the like. The affiliation is a facility where each staff member works, and is one of the first and second medical facilities 12, 15 and the first and second care facilities 13, 17. The rank determines the authority of each staff member to view and enter electronic medical records.
[0020]
The medical server 20 includes a patient master data storage unit 72 for storing patient-specific master data for identifying a patient, a dictionary data storage unit 73 for storing dictionary data such as disease names and drug names, and a user identification server 24. The data stored in the staff data storage unit 71 is sequentially copied, and further includes a staff ranking unit 74 for additionally registering the medical subjects of doctors belonging to the first and second medical facilities 12 and 15. . The storage units 72 and 73 and the staff ranking unit 74 are collectively called a medical database storage unit 77.
Here, the master data is the patient's name, gender, address, date of birth, age, emergency contact information (mobile phone number of company, family, etc.), attending physician, insurance information (contents described on insurance card) Etc., and can identify the individual patient. In addition, the photograph of the patient is stored as digital data and displayed on a medical chart. This can prevent mistakes such as a mistake in the chart.
[0021]
Further, the medical server 20 stores the article data storage unit 75 and the instruction data storage unit 76 in which the standard document described in the medical chart is registered, and the medical data input from the medical clients 28 to 44 and 60 to 63. A medical data storage unit 78. In addition, the medical server 20 is a program for distributing information (for example, examination requests, prescriptions, meal contents, and the like) written in the electronic medical record to each department (that is, each examination unit, pharmacy, kitchen, and the like). And a distribution information storage unit group 80 for storing information distributed to each department by the distribution unit 79. Further, the medical server 20 has an authority having a program for distributing the reference authority and the input authority (that is, the handling of medical data) according to the rank of each of the staff members who refer to and input the electronic medical record based on the staff ranking unit 74. A confirmation unit 81 is provided. Further, the medical server 20 has a document issuing unit 82 having a program for printing a medical chart, issuing a medical certificate, and the like, and an admission / discharge management unit 83 for recording the admission / discharge of a patient. Further, the medical server 20 has a reception data storage unit 83a registered when reception of a patient who has visited the hospital is completed. The reception data storage unit 83a can confirm whether the patient is undergoing a medical examination or is waiting for a medical examination, and is stored in the reception data storage unit 83a as completed after accounting.
[0022]
Here, the article data and the instruction data are a fixed form of a sentence described in a medical chart, and the article data is a description of a patient's symptoms (for example, body temperature, blood pressure, etc.) and a template of a medical examination. The instruction data describes a template such as an examination, a treatment, a prescription of a medicine, and a meal content for a patient. With the article data and the instruction data, a chart can be created simply by entering a numerical value or the like at the time of description. Therefore, no matter who enters the chart, the chart can be created in the same manner.
The medical data is a medical examination result, a doctor's instruction, a test result, a hospitalization record, and the like. The test result may be digital data of an X-ray diagnosis (that is, a radiograph), an image of a CT scan, a chart of an electrocardiogram, an ultrasonic diagnosis, or the like, and may include digital data of voice data such as a heart sound. Further, a moving image of a state such as rehabilitation may be digitized.
[0023]
Next, the distribution information storage unit group 80 in the medical server 20 will be described with reference to FIG. In the sorting information storage unit group 80, an examination information storage unit 80a in which information relating to an examination is stored, an outpatient treatment information storage unit 80b in which treatment information relating to an outpatient is stored, and an inpatient patient in which treatment information relating to an inpatient is stored A treatment information storage unit 80c, a pharmacy information storage unit 80d that stores information to a pharmacy, a rehabilitation center information storage unit 80e that stores information to a rehabilitation center, and an acupuncture room information storage unit that stores information to an acupuncture room. 80f, a kitchen information storage unit 80g for storing information to the kitchen. Note that an information storage unit for storing other information can be added to the distribution information storage unit group 80.
Here, the treatment information regarding the outpatient and the inpatient is information described in a medical chart, such as instructions to a nurse and notes.
[0024]
Next, the care server 21 will be described with reference to FIGS. 2 and 3B. Like the medical server 20, the nursing care server 21 includes a patient master data storage unit 84 for storing master data, a dictionary data storage unit 85 for storing dictionary data such as disease names and drug names, and a user identification server 24. There is a staff ranking unit 86 in which data stored in the staff data storage unit 71 is sequentially copied, and these storage units 84 and 85 and the staff ranking unit 86 are collectively called a nursing database storage unit 89. Further, the nursing care server 21 is input from the article data storage unit 87 and the instruction data storage unit 88 that register the standard document described in the medical chart, and the nursing care clients 49 to 55, 55a to 55d, and 68 to 70. And a care data storage unit 90 for storing care data. In addition, the nursing care server 21 has a distribution unit including a program for distributing information (for example, care plans, meal contents, and the like) written in the electronic medical record to each department (that is, visiting care, kitchen, and the like). 91, and a distribution information storage unit group 92 for storing information distributed to each department by the distribution unit 91.
[0025]
Further, the nursing care server 21 has an authority having a program for distributing the reference authority and the input authority (that is, handling of nursing care data) according to the ranks of the staff members who refer to and input the electronic medical record based on the staff ranking unit 86. A confirmation unit 93 is provided. The nursing care server 21 includes a document issuing unit 94 having a program for printing a medical chart, issuing a care plan, issuing a summary, and the like, and an entrance / exit management unit 95 for recording the entrance / exit of a patient. I have. The care data is a care plan, a care record, and the like.
In addition, the nursing care server 21 has a use patient data storage unit 95b for registering a use patient for each business establishment of the first and second care facilities 13 and 17. Furthermore, when the nursing staff of the nursing facilities 13 and 17 refers to the medical data stored in the medical server 20, the nursing staff 21 takes charge of the nursing staff based on the used patient data storage unit 95b. A medical data reference authority confirmation unit 95c having a program for giving authority to refer to medical data only for patients is provided.
[0026]
Next, the distribution information storage unit group 92 of the nursing care server 21 will be described with reference to FIG. The sorting information storage unit group 92 includes services in the nursing facility, that is, visiting nursing, visiting nursing, outpatient nursing, visiting rehabilitation, outpatient rehabilitation, group home, nursing home for the elderly, rehabilitation center, acupuncture room, pharmacy, and The kitchen is provided with a storage unit in which instructions, schedules, and the like at each business site are sorted.
Here, the above-mentioned storage unit includes a home-visit nursing information storage unit 92a in which scheduled visits to nurses and the like are sorted, a home-visit care information storage unit 92b in which scheduled visits of care staff and the like are sorted, a day care information storage unit 92c, Visiting rehabilitation information storage unit 92d, tsusho rehabilitation information storage unit 92e, group home information storage unit 92f, care for the elderly health facility information storage unit 92g, rehabilitation center information storage unit 92h, acupuncture and moxibustion room information storage unit 92i, pharmacy information storage unit 92j, The kitchen information storage unit 92k. It is also possible to add an information storage unit for storing other information to the distribution information storage unit group 92.
The data in the medical database storage unit 77 and the data in the care database storage unit 89 are individually stored in the medical server 20 and the care server 21, respectively.
[0027]
The electronic medical records 99 to 101 used in the electronic medical record system 10 will be described with reference to FIG. The electronic medical record is created by integrating the above-described master data with one or two of the medical data and the nursing care data. Here, the electronic medical records 99, 100, and 101 of three patients 96, 97, and 98 will be described. The patient 96 uses the first and second medical facilities 12 and 15 and the first and second care facilities 13 and 17, the patient 97 uses the first medical facility 12 and the first care facility 13, The patient 98 uses the second medical facility 15 and the second care facility 17.
The electronic medical record 99 of the patient 96 is input in the master data of the patient 96 stored in the patient master data storage 72 and the first and second medical facilities 12 and 15, and is stored in the medical data storage 78 of the medical server 20. And the nursing care data of the patient 96 input in the first and second care facilities 13 and 17 and stored in the nursing care data storage unit 90 of the nursing care server 21. A medical chart created from the master data and the medical data is referred to as a medical electronic medical chart, and a medical chart created from the master data and the nursing care data is referred to as a nursing electronic medical chart.
[0028]
Similarly, the electronic medical record 100 of the patient 97 includes the master data of the patient 97, the medical data of the patient 97 input at the first medical facility 12, and the care data of the patient 97 input at the first care facility 13. Also, the electronic medical record 101 of the patient 98 includes the master data of the patient 98, the medical data of the patient 98 input at the second medical facility 15, and the patient 98 input at the second care facility 17. It consists of nursing care data. Thus, in the electronic medical record system 10, the same electronic medical record can be created no matter which medical facility or any care facility is used.
[0029]
Next, with reference to FIGS. 5 to 25, a description will be given of a method of entering and referring to the electronic medical record 99 when the patient 96 visits the first medical facility 12 in the electronic medical record system 10.
First, with reference to FIG. 5, a description will be given of a flow of a patient 96 and a medical client associated therewith until the patient 96 receives, for example, a medical consultation (internal medicine outpatient, blood pressure measurement, blood test, etc.) and ends. When the patient 96 visits the first medical facility 12, the patient 96 first performs reception at the reception. At this time, the patient 96 is confirmed by the reception client 28 as to whether the patient 96 is a new visitor or a returning patient.
[0030]
At this time, if the patient 96 is the first consultation in all the facilities of the electronic medical record system 10, the master data is registered. At the general reception, the patient 96 fills out the respective items on a master data registration form having items such as name, gender, address, emergency contact information, date of birth, and age as master data. In addition, in the general reception, the receptionist, in addition to these entered items, the attending physician, insurance information, each system code (used for linking with other systems, for example, an accounting system), etc. as master data. The registration is performed by the reception client 28 in the patient master data storage unit 72 of the medical server 20. The registered data is sequentially copied and stored in the patient master data storage unit 84 of the care server 21. Further, in the general reception, after registration of the master data, reception of the patient 96 to the internal medicine is performed. The reception client 28 stores reception information for the internal medicine of the patient 96 in the reception data storage unit 83a. The visit of the patient 96 can be confirmed by referring to (viewing) the reception data storage unit 83a from the internal medicine client 29. Note that referring to the reception data storage unit 83a refers to browsing an outpatient reception screen (not shown) indicating a patient reception status described later.
[0031]
Further, individual identification symbols of the patients are automatically given in the order of registration in the patient master data storage units 72 and 84, and registered in the patient master data storage unit 72. This identification symbol is described on the consultation ticket of the patient 96. It should be noted that the same patient is given one identification number, and is used in any facility of the electronic medical record system 10 as data for specifying the patient.
When the patient 96 returns, at the reception, the identification code written on the consultation ticket of the patient 96 is input to the reception client 28 and reception is performed. If the consultation ticket is forgotten, the patient can be searched for by the patient's name or the like.
Note that the master data can specify an individual patient, and the items of the patient master data can be increased or decreased as necessary.
[0032]
In addition, at the time of reception, the patient 96 enters the current state of the patient 96 (for example, symptoms such as fever, coughing, sickness, and desire to prescribe medicine, etc.) in an interview table and the like. And submit it to the general reception. In the general reception, the entered data is input by the reception client 28 installed in the general reception. The input data is stored in the medical data storage unit 78.
When the patient 96 is examined by a medical doctor, the doctor knows the current state of the patient 96 by previously viewing the data stored in the medical data storage unit 78 with the medical client 29 for the doctor. Can be.
The patient 96 receives a doctor's consultation and receives, for example, blood pressure measurement and blood test instructions. Patient 96 receives a blood pressure measurement in the treatment room. The result is input by the treatment room client 42 installed in the treatment room, and the input data is stored in the medical data storage unit 78 and the outpatient treatment information storage unit 80b. In addition, patient 96 undergoes a blood test in a blood test room. The result is input by the blood test client 35 installed in the blood test room, and the input data is stored in the medical data storage unit 78 and the test information storage unit 80a.
[0033]
After the treatment and the examination according to the doctor's instruction are completed, the patient 96 receives the doctor's consultation again in the internal medicine, and the consultation ends. Further, after the consultation, the treatment and the examination may be performed again. The consultation is completed. Here, when there is a prescription for the medicine, the doctor inputs the prescription for the medicine to the internal medicine client 29 and stores it in the medical data storage unit 78. This data is stored in the pharmacy information storage unit 80d of the distribution information storage unit group 80 by the data distribution program provided in the distribution unit 79. Here, in the pharmacy, the pharmacy client 43 refers to the pharmacy information storage unit 80d, confirms the doctor's prescription, and prepares a medicine.
Patient 96 receives the medication at the pharmacy, completes the accounting and ends. In addition, the patient 96 can go to a medical department different from the internal medicine. In this case, after the consultation of the internal medicine is completed, a consultation is performed at another consultation department, and after the completion of all consultations, if there is a prescription for the drug, the drug will be received at the pharmacy and the transaction will be completed at the end. It becomes.
[0034]
Next, the internal medicine client 29 of the internal medicine doctor will be described with reference to FIGS.
As shown in FIG. 6 and FIG. 7, the doctor of the internal medicine activates the client 29 for the internal medicine for the doctor (for example, a PC installed on the desk of the doctor) before performing the medical examination. At this time, the doctor's PC identification symbol and password are entered on the PC password input screen 102.
After the PC is started, the electronic medical record system program is started. This electronic medical record system program is created by database software (for example, Lotus Notes manufactured by IBM Japan, Ltd.). Here, on the password input screen 103 of the electronic medical record system 10, the identification symbol and the password of the doctor for the electronic medical record system 10 are input. The input data (identification symbol) is confirmed (authenticated) by the user (that is, this doctor) by the staff data storage unit 71 in the user identification server 24, and further, by the medical server 20. In the authority confirmation section 81, the identification symbol is confirmed, and the input authority and the reference authority of the electronic medical record of this doctor are determined. When the doctor leaves the desk, the electronic medical chart system program must be terminated in order to prevent a person other than the doctor from operating the PC and viewing the electronic medical chart of the patient.
[0035]
When the input identification symbol is confirmed by the staff data storage unit 71 to be a medical worker (for example, a doctor, a nurse, a laboratory technician, a pharmacist, etc.), the medical menu screen 104 is displayed. When the doctor views the medical electronic medical chart of the patient 96 whose reception has been completed, the doctor switches from the medical menu screen 104 to the outpatient reception screen. The person who has finished the reception is displayed on the outpatient reception screen. Here, the doctor selects the patient 96 and displays the medical electronic medical chart screen 106 of the patient 96. Further, the screen is switched from the medical menu screen 104 to the patient search screen 105. In the patient search screen 105, symbols unique to the patient (eg, patient identification symbol, patient's last name, patient's first name, kana last name, kana name, phone number, etc.) Is input, a search is performed, and the medical electronic medical chart screen 106 can be displayed.
The medical data that can be handled by the doctor is all data related to medical treatment, such as medical examination results, determination of whether to perform an examination, prescription of medicine, and the like. Further, the doctor can also refer to nursing care data performed at the nursing facility as needed.
[0036]
After the search for the patient 96 is completed, a medical electronic medical chart screen 106 of the patient 96 is displayed as shown in FIG. The medical electronic medical chart screen 106 has a patient information display unit 107 on which a patient identification code (patient ID), name, date of birth, age, gender, and entry / outpatient division (to distinguish an inpatient or outpatient) are displayed. , A display menu unit 108 for selecting a program for displaying medical data of a patient, and an input menu unit 109 for selecting items to be input to the electronic medical record. The medical electronic medical chart screen 106 includes a calendar display unit 110 that displays a schedule of examination, treatment and the like of the patient 96, instructions from a doctor, and the patient's symptoms in a time series. The display menu unit 108 and the calendar display It has a data display unit 111 for displaying information or the like selected by the unit 110.
Hereinafter, the display menu unit 108 and the input menu unit 109 of the medical electronic medical chart screen 106 will be described in detail with reference to FIGS.
[0037]
The display menu unit 108 selects data stored in the medical server 20 and displays seven items (basic information, medical history, hospital visit history, hospitalization history, memo, summary, photograph) to be displayed on the data display unit 111, respectively. 5 screens (Clinical test results, thermometry table, CAPD (continuous dialysis trial, continuous peritoneal dialysis, continuous peritoneal dialysis) drainage table, chart browser, blood glucose list) connected to the medical client One item for printing on a completed printer or network printer, and one item for displaying patient master data (patient master display).
These items are “basic information” and “photograph” stored in the patient master data storage unit 72, and “patient history”, “clinical test result”, and “temperature measurement” of the patient stored in the medical data storage unit 78. There are a "table", a "CAPD drainage table", a "memo", and a "blood glucose level list", and these data can be displayed.
[0038]
Here, the “patient master display” is a function of displaying personal data such as a patient's name, gender, date of birth, age, address, contact information, and attending physician stored in the patient master data storage unit 72. . “Basic information” is a function for displaying information necessary for performing medical practice, such as height, weight, blood type, contraindicated information, allergy information, and infectious disease information of a patient. The “memo” has a function of, for example, registering the symptoms in the medical data storage unit 78 in advance when the patient says “headache” at the reception. The doctor can grasp the patient's symptoms by looking at the memo before the patient's consultation. In addition, points to be noted and points to be confirmed by the patient at the next visit of the patient can be registered to reduce transmission errors and confirmation errors. “Photo” is a function that allows browsing of data obtained by capturing a patient's face with a digital camera and data obtained by scanning a patient's face with a scanner. As a result, mistakes such as patient misunderstanding can be prevented.
[0039]
The “summary” designates a specific content from the patient's medical data stored in the medical data storage unit 78 based on the template (standard document) registered in the article data storage unit 75. This function is mainly used by doctors when telling patients to another person in charge (department, business office), and special notes, precautions, medicines taken by patients, etc. This is an aggregated document. Further, the “visit history” and the “hospital history” stored in the admission / discharge management unit 83 can also be displayed. Further, the display menu unit 108 has a “chart printing” for printing the chart by the above-mentioned printer and a “chart browser” for displaying the chart on the monitor screen by the document issuing unit 82.
[0040]
As shown in FIG. 8, the display menu unit 108 includes five screens that are switched from the medical electronic medical chart screen 106 and displayed, that is, a clinical test result screen 112 that displays a clinical test result, and a doctor in a doctor 2 paper format. Browser screen 113 for displaying instructions and articles from the patient, a thermometry list screen 114 for displaying the results of body temperature measurement in a graph, a blood glucose level list screen 115 for displaying blood glucose levels in a list format, and a list of CAPD treatment records in a list format. A CAPD drainage table screen 116 is displayed. Hereinafter, these screens 112 to 116 will be described in detail with reference to FIGS.
As shown in FIG. 9, a clinical test result screen 112 includes a patient information section 112a for displaying patient information, a test result display section 112b for displaying clinical test results in chronological order, and numerical values for each item of the test results. It comprises a reference value display section 112c for displaying a reference value, a selection section section 112d for selecting data to be displayed for each section of the inspection result, and a print processing section 112e for printing the result displayed on the inspection result display section 112b. You. The inspection result display unit 112b can display the input result in a time-series format. In addition, by selecting only an item having an inspection in the selection section 112d, it is also possible to display only the result of the inspection item to be checked on the inspection result display portion 112b. The print processing unit 112e can print the result displayed on the inspection result display unit 112b as it is. Thereby, the paper on which the test result is printed can be handed to the patient.
[0041]
As shown in FIG. 10, the chart browser screen 113 includes a patient information section 113a, an article information display section 113b in which an article document in which a patient's condition is entered is displayed, and an instruction information display section in which an instruction document from a doctor is displayed. 113c and a date changing unit 113d. On the chart browser screen 113, data is summarized and displayed for each date. By operating the date change unit 113d, the date can be changed and the contents of the article information display unit 113b and the instruction information display unit 113c can be switched to the contents when the patient had previously visited the hospital. On the medical chart browser screen 113, the content input to the medical electronic medical chart can be displayed in the form of a conventional medical chart described on paper, that is, in the “doctor's second paper” format. This allows the physician to check in the form of a conventional, familiar paper chart. The display format of the chart browser screen 113 may be changeable, and may be displayed in various formats other than the “doctor No. 2 paper” format.
[0042]
As shown in FIG. 11, the temperature measurement list screen 114 is mainly used when displaying data such as the body temperature of an inpatient. The temperature measurement list screen 114 has a time display unit 114a for displaying a measurement date and a measurement time, and a result display unit 114b for displaying measured values of body temperature, blood pressure, and pulse by numerical values. In addition, the graph display unit 114c displays the measured values of the body temperature, the blood pressure, and the pulse in a graph format, and can check the input values in a time series. Further, the temperature measurement list screen 114 has an observation item display section 114d for displaying observation items such as blood pressure, so that the patient's condition can be grasped.
As shown in FIG. 12, the blood glucose level list screen 115 has a doctor instruction column 115a in which a doctor inputs an insulin administration instruction, and an enforcement column 115b displayed when the patient actually administers insulin administration. I have. In the doctor instruction column 115a, the name and administration unit of the administered insulin are displayed, and in the enforcement column 115b, the administered insulin name, administration unit, administration site, and an enforcement mark indicating that the administration is performed are displayed. . When the blood glucose level list screen 115 is printed, it can be used as a confirmation table.
As shown in FIG. 13, the CAPD drainage table screen 116 has a date display section 116a for displaying the date of the treatment, a CAPD treatment display for recording the treatment time, the name of the dialysate, the time of the CAPD treatment, and the like. The unit 116b has a CAPD total amount display unit 116c for automatically calculating and displaying the total amount of water removal on the day of the treatment based on the CAPD treatment display unit 116b. In the CAPD treatment display section 116b, a CAPD treatment can be entered up to five times a day.
[0043]
As shown in FIG. 8, an input screen for assisting in inputting an electronic medical record is registered in the input menu unit 109. When an electronic medical record is to be entered, a template is displayed from the medical electronic medical chart screen 106. It is possible to switch to a plurality of, for example, twelve input screens in which (fixed form documents) are registered. By using these templates, medical records can be easily created. In general, the medical record describes symptoms and names of patients, instructions of doctors, test results, prescriptions of drugs, and the like. Here, the input menu unit 109 includes a “disease name” for inputting a patient's disease name, an “article” for inputting a patient's symptoms (for example, body temperature, blood pressure, etc.), an “injection” for inputting instructions from a doctor, and the like. "Radiation", "Clinical examination", "Pattern", "Critical path (treatment plan)" and "Others", "Drug" for inputting prescription and use instructions of the drug, and record of test results etc. Input screens 117 to 128 (see FIGS. 14 to 25) having templates for inputting “temperature reading table”, “blood glucose level”, and “CAPD drainage table” are provided. Switch to the input screen and enter the medical electronic medical record.
[0044]
On the medical electronic medical record screen 106, there are twelve screens switched and displayed from the input menu unit 109, that is, a medicine instruction input screen 117 for inputting an instruction relating to a medicine, and an injection instruction input screen 118 for inputting instructions such as injection and infusion. , A radiological examination instruction input screen 119 for inputting a test instruction using radiation, a clinical test instruction input screen 120 for inputting a blood test instruction, a miscellaneous instruction input screen 121 for inputting other instructions, an instruction for a radiological test or a medicine, etc. A pattern instruction input screen 122 for inputting a plurality of items collectively, a critical path input screen 123 for inputting instructions such as treatments and examinations in chronological order, an article input screen 124 for inputting symptoms of a patient, and a disease name input screen 125 for inputting a disease name. , Input temperature measurement result input screen 126, CAPD record input screen 127, input blood glucose level That has a blood sugar value input screen 128. Hereinafter, these screens 117 to 128 will be described in detail with reference to FIGS.
[0045]
As shown in FIG. 14, the medicine instruction input screen 117 includes a patient information section 117a, an instruction item section 117b, a prescription medicine search section 117c for searching for a medicine to be used, a prescription medicine information section 117d for displaying information on the selected medicine, A prescription medicine setting section 117e for inputting a medication method and various precautions, and a prescription instruction content display section 117f for displaying contents actually described in a medical chart as medicine instructions are provided.
In the prescription drug search unit 117c, a dictionary data storage unit 73 for storing dictionary data such as a disease name and a drug name in the medical server 20 and a pre-registered combination of medicines from the instruction data storage unit 76, kana, And a function to search based on conditions such as drug efficacy and the like, and a function to call past prescription instructions. In the prescription drug search section 117c, a medical department or the like can be set in the instruction item section 117b in advance, and the medicine to be called can be restricted. This restriction can be changed in the dictionary data storage unit 73 and the instruction data storage unit 76. The prescription drug information section 117d displays the details such as the prescription classification and usage of the selected drug by selecting the drug or the combination of the drugs displayed in the prescription drug search section 117c. Also, the prescription instruction content display section 117f displays the medicine selected by the prescription medicine search section 117c and added to the list, or the add button pressed on the add to all list button. At this time, a plurality of drugs can be selected. The prescription medicine setting section 117e is used when changing the prescription classification and usage of the medicine displayed on the prescription instruction content display section 117f, and inputting various precautions.
[0046]
As shown in FIG. 15, the injection instruction input screen 118 includes a patient information section 118a, an instruction item section 118b, a medicine search section 118c for searching for a medicine used for injection and infusion, and a medicine information section for displaying information on the selected medicine. 118d, a medicine setting section 118e for changing the instruction of the procedure at the time of injection or infusion, etc., and an injection and infusion instruction content display section 118f for displaying the contents actually described on the medical chart as the injection and infusion instruction. I have. In the instruction item section 118b, it is possible to limit the medicine to be used by inputting the instruction (instruction classification) of injection or infusion and selecting a medical department. The medicine search unit 118c searches the dictionary data storage unit 73 and the instruction data storage unit 76 based on instructions registered in advance by combining medicines, kana, and conditions such as medicinal effects, and searches past prescription instructions. Call display can be. The calling of the medicine can be restricted according to the instruction section input in the instruction item section 118b, the medical department, or the like. This restriction can be changed in the dictionary data storage unit 73 and the instruction data storage unit 76 as in the case of the medicine instruction. In the medicine information section 118d, by selecting a medicine or a combination of medicines displayed in the medicine search section 118c, details such as a procedure and an administration method of the selected medicine are displayed. The injection and infusion instruction content display section 118f displays the medicine selected and added to the list by the medicine search section 118c or the add button pressed to the entire list. At this time, a plurality of drugs can be selected. The medicine setting section 118e is used when changing the technique or administration method of the medicine displayed on the injection and infusion instruction content display section 118f, and when inputting various precautions. In addition, the injection instruction input screen 118 can input an instruction of a treatment using a medicine as well as an injection or an infusion by increasing the number of instruction sections.
[0047]
As shown in FIG. 16, the radiation examination instruction input screen 119 includes a patient information section 119a, an instruction item section 119b, an examination instruction search section 119c, an examination information section 119d displaying the contents of the selected examination instruction, and an examination instruction search section 119c. As a result of the search in, when there is no corresponding test content item, a test content input unit 119e for inputting the test content in a selective manner, when issuing a test instruction, the test conditions, the contrast agent to be used, and the equipment used , A test supplementary instruction input unit 119f for inputting comments, etc.
As shown in FIG. 17, the clinical test instruction input screen 120 includes a patient information section 120a, an instruction item section 120b, a test instruction search section 120c, and an examination information section 120d displaying the contents of the test instruction selected in the test instruction search section 120c. A test content input unit 120e for inputting test content in a selective manner for each selected clinical test item, and a test supplementary instruction input unit 120f for inputting test conditions and comments when issuing test instructions. .
[0048]
As shown in FIG. 18, the other instruction input screen 121 is a screen for inputting instructions other than medicine, injection and infusion, radiation, and clinical examination, for example, instructions such as echocardiography, urinalysis, wound treatment, and hospitalization. Instructions such as a patient's meal sheet and suturing procedure can be input. The other instruction input screen 121 includes an instruction display section 121c on which an instruction type selected from various instructions in the patient information section 121a, the instruction item section 121b, and the instruction item section 121b is displayed, and an instruction selected on the instruction display section 121c. The instruction information section 121d for displaying the contents of the instruction, the selection instruction display section 121e for displaying the instruction selected in the instruction display section 121c, the contents are input in a selective manner for each item displayed on the selection instruction display section 121e, or directly. An instruction content input section 121f to be input, a selection content display section 121g selected or displayed on the instruction content input section 121f, and a supplementary instruction input for inputting inspection conditions and comments when issuing an inspection instruction. A portion 121h is provided.
[0049]
As shown in FIG. 19, a pattern order input screen 122 displays a pattern order registered for each medical subject by selecting a medical subject in the patient information section 122a, the instruction item section 122b, and the instruction item section 122b. Section 122c, a pattern order information section 122d for displaying the contents of the pattern order displayed on the pattern order display section 122c by selecting the pattern order, a selected pattern order display section 122e for displaying the selected pattern order, and contents of the selected pattern order display section 122e. Is displayed. Here, for example, when performing a health check, a health check is selected from a plurality of pattern orders in the pattern order display section 122c. By this selection, radiation (X-ray), clinical test (blood test), and electrocardiogram are displayed in the selected pattern order display section 122e, and by registering these, it is possible to write in the medical chart. Normally, in order to write these in the medical chart, they must be input from the radiological examination instruction input screen 119, the clinical test instruction input screen 120, and the other instruction input screen 121, respectively. You can write it on the chart on the screen.
[0050]
As shown in FIG. 20, the critical path input screen 123 is a critical path display for displaying a registered critical path for each medical subject by selecting a medical subject in the patient information section 123a, the instruction item section 123b, and the instruction item section 123b. Unit 123c, a critical path information unit 123d that displays the content of the critical path displayed on the critical path display unit 123c by selecting the critical path, a selected critical path display unit 123e that displays the selected critical path, and contents of the selected critical path display unit 123e. Is displayed on the display section 123f.
[0051]
As shown in FIG. 21, the article input screen 124 includes a creation information section 124a for inputting a date and a creator, a patient information section 124b, and an instruction item section 124c. The article input screen 124 has an article classification unit 124d having three levels of categories so that articles stored in the article data storage unit 75 can be classified and input easily, and an article selected by the article classification unit 124d can be input. An input format selection unit 124e for inputting the content to be input is provided, an article display unit 124f for displaying the article selected by the input format selection unit 124e, and a reference material display unit 124g for displaying reference materials. The reference material display section 124g can attach and display a digitalized document from a document, a diagrammatic representation of an affected part, or the like.
[0052]
As shown in FIG. 22, the disease name input screen 125 includes a creation information section 125a for inputting a date and a creator, and a patient information section 125b. In addition, the disease name input screen 125 is used to enter a start date when the doctor diagnoses the disease, an end date when the disease is completely cured, a reason for the end, a disease name category for entering whether the disease name is confirmed or suspected, and a disease site. It has a disease information section 125c having a site to perform. Further, the disease name input screen 125 includes a dictionary data readout unit 125d for displaying data stored in the dictionary data storage unit 73, a disease name content display unit 125e for displaying the selected disease name on the dictionary data readout unit 125d, and a name attached to the disease name. A common recognition code display unit 125f for displaying a common recognition code (ICD10) in the medical field, and a reference material display unit 125g for displaying reference materials. Here, the use of the common recognition code is convenient when collecting statistics. The reference material display 125g is the same as the reference material display 124g.
[0053]
As shown in FIG. 23, the temperature measurement result input screen 126 is mainly used when inputting data such as the body temperature of an inpatient. The temperature measurement result input screen 126 includes a time input section 126a for inputting a measurement date and a measurement time, a doctor input section 126b for inputting a medical department and a doctor's name, and a result input section 126c for inputting measured values of body temperature, pulse, and respiration numerically. And an observation item input section 126d for inputting observation items such as blood pressure and the like.
As shown in FIG. 24, the CAPD record input screen 127 includes a time input unit 127a for inputting a measurement date, a measurement start time and an end time of a CAPD treatment, and a doctor input unit 127b for inputting a medical department and a doctor name. . The CAPD record input screen 127 is a result input section 127c for inputting data such as the name of the dialysate, the time only for drainage in the CAPD process, the time required for only injection, the amount of drainage, and the amount of injection. It has.
As shown in FIG. 25, the blood sugar level input screen 128 for inputting a blood sugar level includes a time input section 128a for inputting a measurement date and a measurement time, and a doctor input section 128b for inputting a medical department and a doctor name. In addition, the blood sugar level input screen 128 includes a trial for writing a time zone (morning, noon, evening, etc.) in which the blood sugar level was measured, a blood sugar level for writing the measured blood sugar level, a site for writing the site to which insulin was administered, and administration. And a result input unit 128c having a unit for writing the administered dose of insulin.
[0054]
When the doctor examines the patient 96, the doctor can know the current situation of the patient 96 by viewing the medical electronic medical chart screen 106 in advance. The data described in the medical questionnaire submitted by the patient 96 to the general reception is input from the article input screen 124 in the general reception reception client 28 and stored in the medical data storage unit 78. The input data is displayed as a headline of the article on the calendar display unit 110 of the medical electronic medical chart screen 106, and the doctor can select the headline and display the contents of the article on the data display unit 111 to know the article. . This eliminates the need for the patient 96 to say many times about symptoms and the like.
The doctor inputs instructions for blood pressure measurement and blood test with the medical client 29 and stores them in the medical data storage unit 78. This data is stored in the examination information storage unit 80a and the outpatient treatment information storage unit 80b of the distribution information storage unit group 80 by the data distribution program provided in the distribution unit 79.
[0055]
Further, the doctor causes the patient 96 to undergo an examination according to the symptoms of the patient 96. For example, when performing a blood test on the patient 96, the doctor selects “clinical test” in the input menu unit 109. When a clinical test is selected, a clinical test instruction input screen 120 is displayed, and various blood test instruction data can be set. For example, when a blood sugar level in a blood test item is selected and determined, it is stored in the medical data storage unit 78 of the medical server 20. The blood glucose level measurement instruction stored in the medical data storage unit 78 is stored in the test information storage unit 80a of the distribution information storage unit group 80 by the data distribution program provided in the distribution unit 79. In the blood test client 35, the request for measuring the blood sugar level of the patient 96 can be confirmed. In the blood test room, data of the patient 96 can be viewed from the blood test client 35. Further, the measurement result of the blood sugar level of the patient 96 is referred from the blood test client 35 to the test information storage unit 80a, a blood sugar level measurement instruction is selected, and the blood sugar level measurement result is input and stored. The blood glucose measurement result stored in the test information storage unit 80a is stored in the medical data storage unit 78.
[0056]
As described above, when the doctor selects and decides an examination item (for example, radiation or clinical examination), the data can be confirmed in the medical clients 35 to 41 of the examination room related to the selected item. Further, by inputting the measured values in the medical clients 35 to 41 in the respective examination rooms, the respective test results can also be stored in the medical data storage unit 78.
Further, image data such as an X-ray examination, an ultrasonic examination, and a CT examination can be stored in the medical data storage unit 78 as digital data by a scanner or the like.
After the completion of all examinations instructed by the doctor, that is, when all examination results are stored in the medical data storage unit 78, the medical client 29 notifies the calendar display unit 110 that the examination of the patient 96 has been completed. You can check.
[0057]
When the doctor examines the patient 96 whose examination has been completed again, the doctor can refer to the examination result of the patient 96 in advance before the examination. The input of the doctor's consultation result is performed by “article” and “disease name” in the input menu section 109 of the medical electronic medical chart screen 106. In the “critical path”, examination, treatment, surgery, care, and the like of the patient 96 are input in chronological order. Furthermore, the examination may be performed again after the consultation. If the medical examination is completed and there is a prescription for the medicine, the prescription for the medicine is entered on the medicine instruction input screen 117 for “drug” or the pattern instruction input screen 122 for “pattern” in the input menu unit 109, and the medical server 20 It is stored in the medical data storage unit 78. This data is stored in the pharmacy information storage unit 80d by the data distribution program provided in the distribution unit 79, and can be confirmed by the pharmacy client 43.
When the preparation of the medicine is completed, the pharmacy refers to the pharmacy information storage unit 80d, selects the prescription of the patient 96, and inputs the completed record. This input data is stored in the pharmacy information storage unit 80d and also in the medical data storage unit 78.
[0058]
Next, a case in which the electronic medical record system 10 receives visiting care and visiting nursing at a care facility will be described. Services in nursing homes include home nursing, home nursing, home rehabilitation, outpatient nursing, outpatient rehabilitation, dementia-responsive living co-care, nursing care for the elderly, nursing care for short-term care, pharmacy, rehabilitation, acupuncture and moxibustion.
When the patient uses the services of the nursing facility for the first time, it is necessary to register the patient in the use patient data storage unit 95b of the nursing facility (office) of each service and to create a nursing electronic medical record. .
Here, a description will be given of a method of entering and referring to an electronic medical record when the patient 96 visits the first nursing home 13 in the morning, receives day care, and receives visiting nursing in the afternoon. In the case where the electronic medical record entry method and the reference method when visiting the first medical facility 12 described above are the same as those described above, detailed description will be omitted.
[0059]
The use schedule of the outpatient care of the patient 96 at the first care facility 13 is created in advance by the care manager and described in the service provision slip. The contents described in this service provision form are previously taken into the electronic medical record as a service schedule. Thus, the outpatient care manager knows that the patient 96 is scheduled to use the outpatient care at the first care facility 13 in the morning. Here, the outpatient care manager inputs the instructions described in the service provision slip into the care data storage unit 90 in the care server 21 in the outpatient care client 51. The instruction is stored in the clinic care information storage unit 92c of the distribution information storage unit group 92 for storing the allocated information by the distribution unit 91 having a program for distributing information to each department. At this time, even when the patient 96 uses the first care facility 13 for the first time, since the patient 96 is visiting the first medical facility 12, the patient 96 is stored in the patient master data storage unit 84 of the care server 21. The master data of the outpatient care center can be referred to the master data.
The care worker in charge of the patient 96 refers to the care data of the patient 96 stored in the tsusho care information storage unit 92c in the care server 21 to check the care content and care for the patient 96. After the care of the patient 96 is completed, the care staff member in charge of the patient 96 returns to the tsusho care station of the first care facility 13 and inputs care data using the tsusho care client 51.
[0060]
Here, a method in which a care worker refers to the electronic medical record 99 of the patient 96 will be described with reference to FIGS. 6, 7, and 26. The care worker activates the tsusho care client 51 installed at the tsusho care station. At this time, the identification code and the password of the care staff for the PC are input on the password input screen 102 of the PC. After the PC is started, the electronic medical record system program is started. Here, on the password input screen 103 of the electronic medical record system 10, the identification code and password of the care staff for the electronic medical record system 10 are input.
The input data is used to confirm the user by the staff data storage unit 71 in which the rank and job type of the staff registered in the user identification server 24 are registered, and to the staff ranking unit 86 by the identification code. The authority checking unit 93 having a program for handling the care data according to the rank is checked, and the input authority and the reference authority of the electronic medical record are determined.
[0061]
Here, the staff data storage unit 71 allows the identification symbol to be changed to a care worker (for example, visiting care, visiting nursing, visiting rehabilitation, outpatient nursing, outpatient rehabilitation, dementia-responsive living joint nursing, nursing home for the elderly, pharmacy, rehabilitation If it is confirmed that the person is a worker in a center, an acupuncture room, a kitchen, or the like), a care menu screen 129 is displayed. The care staff refers to the sorting information storage unit group 92 when inputting the care data of the patient 96, and refers to the care instruction information of the department to which the care staff belongs stored in the sorting information storage unit group 92. Enter and save care data. The nursing care data stored in the sorting information storage unit group 92 is also stored in the nursing data storage unit 90. Further, in order to display the nursing electronic medical chart screen 130, the user switches from the nursing care menu screen 129 to the patient search screen 105, and uses a patient-specific symbol (for example, patient identification symbol, patient's last name, patient's first name, kana last name, kana last name). Name, telephone number, etc.) to search and display.
The nursing care staff can input only the patients who use the department to which the nursing care data belongs, and can refer to all the patients who use the nursing care service. For medical data, only the patients who use the department to which they belong can be referred to.
[0062]
As shown in FIG. 27, after the search for the patient 96 is completed, the nursing electronic medical chart screen 130 of the patient 96 is displayed. On the electronic medical chart screen for nursing care 130, the “visit history” in the display menu section 108 of the medical electronic medical chart screen 106 (see FIG. 8) is replaced with the “hospital history”, and the “patient master” is displayed at the place of the “hospital history”. Display has moved. The electronic medical chart screen for nursing care 130 has a patient information display section 131, a display menu section 132, an input menu section 133, and a calendar display section 134, like the medical electronic medical chart screen 106, and includes a display menu section 132 and a calendar display section. It has a data display section 135 for displaying the information selected in 134 and the like.
The care staff can read information to be referred from the display menu section 132 of the electronic medical chart screen for care 130.
In addition, when visiting care or tsusho rehabilitation is performed, a medical chart can be input from the input menu 133 of the electronic medical chart screen 130 for care. After the end of the nursing, when the information is transmitted to the nursing server 21 from the visiting nursing client 50 and the tsusho rehabilitation client 53, the nursing data is stored in the nursing data storage unit 90 in the nursing server 21.
[0063]
Next, a description will be given of an electronic medical record entry method and a reference method when the patient 96 uses home-visit nursing by a nurse at the first care facility 13.
The use schedule of the visit nursing at the first care facility 13 of the patient 96 is created in advance by the care manager and described in the service provision slip. The contents described in this service provision form are previously taken into the electronic medical record as a service schedule. Accordingly, the manager of the home-visit nursing knows that the patient 96 is going to use the home-visit nursing at the first care facility 13 in the afternoon. Based on this, the home-visit nursing administrator inputs an instruction to the home-care data storage unit 90 in the home-care server 21 in the home-visit nursing client 49. The instruction is stored in the visiting nursing information storage unit 92a of the distribution information storage unit group 92 that stores the distributed information by the distribution unit 91 having a program for distributing information to each department. In the present embodiment, the home nursing home 13 is used for visiting nursing care in the morning, so the master data of the patient 96 is stored in the patient master data storage unit 84 of the nursing care server 21. The nurse in charge of the patient 96 checks the nursing contents by referring to the nursing care data of the patient 96 stored in the nursing care data storage unit 90 in the nursing care server 21 using the nursing care client 49 at the nursing home. It is also possible to know the condition of the patient 96 in the morning home visit. Thereafter, the nurse in charge of the patient 96 visits the patient 96 to perform nursing, returns to the visiting nursing home of the first nursing facility 13, and inputs nursing data with the nursing client 49.
[0064]
Next, a description will be given of a case where the patient 96 visits the second medical facility 15 and receives a medical examination. The patient 96 performs reception at the reception client 60 of the second medical facility 15. The reception client 60 performs a patient search, and refers to the patient information from the medical server 20 in the first medical facility 12. When the patient 96 first visits the second medical facility 15, the patient 96 may be connected to another facility in the electronic medical record system 10 (that is, the first medical facility 12, the first care facility 13, and the second If the master data is registered in any of the nursing homes 17), the master data of the patient 96 is stored in the patient master data storage unit 72 in the medical server 20, so that there is no need to input it again. It does not require the time and effort of the patient 96 and the receptionist. In addition, a doctor who examines for the first time can check medical data of the patient 96 by the medical client 61 in the second medical facility 15. The process from the reception of the patient 96 to the checkout can be performed in the same manner as in the first medical facility 12.
[0065]
In addition, a description will be given of a case in which the patient 96 receives visiting care at the second care facility 17.
The use schedule of the visit care of the patient 96 is created in advance in the service provision slip created by the care manager. This is stored in the electronic medical record in advance as a service schedule. Based on this, the manager of the home-visit care inputs the instruction to the home-care data storage unit 90 in the home-care server 21 in the home-visit client 69. The instruction is stored in the visiting care information storage unit 92b of the distribution information storage unit group 92 for storing the distributed information by the distribution unit 91 having a program for distributing information to each department.
The care staff member in charge of the patient 96 refers to the nursing data of the patient 96 stored in the nursing data storage unit 90 in the nursing server 21 to check the contents of the nursing care and visits the patient 96 to perform nursing care. After completing the care of the patient 96, the care staff member in charge of the patient 96 returns to the visiting care house of the second care facility 17, and inputs care data using the visiting care client 69.
[0066]
The present invention is not limited to the above-described embodiments, and changes can be made without departing from the spirit of the present invention. For example, some or all of the above-described embodiments and modifications are combined. The electronic medical record system of the present invention is also included in the scope of the present invention.
For example, in the electronic medical record system described in the above embodiment, the number of medical facilities and nursing facilities is two, but the present invention can be used in many medical facilities and nursing facilities. In the electronic medical record system of the present invention, the medical and nursing care data of a patient can be treated as data of one medical record, regardless of the input from any facility. May be used. For example, if a patient becomes ill outside his place of residence, going to a hospital that has a medical client working with a medical server will provide medical data for that patient. Will be able to take appropriate measures.
In the medical facility and the nursing care facility, the number of medical departments may be increased.
May work with accounting.
[0067]
In addition, the medical client and the nursing care client are both connected by a cable, but can be connected to an electronic medical record system using a communication means such as a mobile phone with a portable client such as a notebook computer. . As a result, the master data, medical data, and nursing care data can be referenced and input outside the medical facility or nursing care facility such as a doctor's home visit, visiting nursing care, visiting rehabilitation, and visiting nursing care. However, the use of the Internet network requires a security system that prevents invasion of electronic medical record systems other than those concerned.
Alternatively, a pharmacy may be provided in the electronic medical record system, and drug data may be transmitted to a pharmacy desired by the patient.
Further, since image, sound, and chart data are large in capacity, they may be stored in another dedicated server and linked.
[0068]
【The invention's effect】
In the electronic medical record system according to claims 1 to 5, a master data for specifying a patient, a server for managing patient's medical data and patient's care data, and a server which cooperate with the server and are arranged in a medical facility to become master data A medical client capable of inputting the described medical data of a patient, and nursing care that is arranged in a nursing facility in cooperation with a server and capable of inputting the nursing care data of the patient described in the master data. Since the medical client and the nursing client can refer to the patient master data, medical data, and nursing data registered in the server from both the medical client and the nursing client, the input of the patient master data is Only once at the institution or nursing home, the patient does not have to write the same information over and over. Further, the medical worker and the care worker can refer to the information of the patient that is performed or observed in the medical facility and the care facility from both the medical client and the care client, respectively.
[0069]
In particular, in the electronic medical record system according to the second aspect, since there are a plurality of medical facilities provided with medical clients and / or nursing facilities provided with nursing clients, the number of medical facilities and the number of nursing homes are increased. Information can be shared, and patients do not have to go to the same medical facilities and care facilities at all times.
In the electronic medical record system according to claim 3, the server has a medical server in which medical data is stored and a nursing server in which nursing data is stored, and furthermore, each of the medical server and the nursing server Since the master data having the same contents are stored separately, the medical server and the nursing care server are linked with the medical client and the nursing care client, respectively, so that leakage of the medical data and the nursing care data can be easily prevented. In addition, since the same master data is stored in each server, it is only necessary to register at one of the facilities.
[0070]
In the electronic medical record system according to the fourth aspect, individual identification symbols for identifying individuals are registered in advance in the server for the medical staff of the medical facility and the caregiver of the nursing facility, and data input and identification can be performed by the identification symbols. Since the referenceable range is determined, the inputtable and referenceable range is determined by the identification symbol, thereby preventing leakage and rewriting of various data.
In the electronic medical record system according to the fifth aspect, the server may include a personal identification server in which an identification symbol is registered. Thereby, the server in which the identification symbol is registered is provided separately from the server storing the medical data and the nursing care data, so that leakage and rewriting of various data can be easily prevented, and the maintainability is improved.
[Brief description of the drawings]
FIG. 1 is an explanatory diagram of an electronic medical record system according to an embodiment of the present invention.
FIG. 2 is an explanatory diagram of a server of the electronic medical record system.
FIGS. 3A and 3B are explanatory diagrams of distribution information storage units of a medical server and a nursing care server, respectively.
FIG. 4 is an explanatory diagram of an electronic medical record of the electronic medical record system.
FIG. 5 is an explanatory diagram showing a relationship between a patient flow and a medical client in the electronic medical record system.
FIG. 6 is a flowchart of electronic medical record entry of the electronic medical record system.
FIG. 7 is an explanatory diagram showing transition of a screen of a client of the electronic medical record system.
FIG. 8 is an explanatory diagram of a medical electronic medical record screen of the electronic medical record system.
FIG. 9 is an explanatory diagram of a clinical test result screen.
FIG. 10 is an explanatory diagram of a chart browser screen.
FIG. 11 is an explanatory diagram of a temperature measurement list screen.
FIG. 12 is an explanatory diagram of a blood sugar level list screen.
FIG. 13 is an explanatory diagram of a CAPD drainage screen screen.
FIG. 14 is an explanatory diagram of a medicine instruction input screen.
FIG. 15 is an explanatory diagram of an injection instruction input screen.
FIG. 16 is an explanatory diagram of a radiological examination instruction input screen.
FIG. 17 is an explanatory diagram of a clinical test instruction input screen.
FIG. 18 is an explanatory diagram of another instruction input screen.
FIG. 19 is an explanatory diagram of a pattern instruction input screen.
FIG. 20 is an explanatory diagram of a critical path input screen.
FIG. 21 is an explanatory diagram of an article input screen.
FIG. 22 is an explanatory diagram of a disease name input screen.
FIG. 23 is an explanatory diagram of a temperature measurement result input screen.
FIG. 24 is an explanatory diagram of a CAPD record input screen.
FIG. 25 is an explanatory diagram of a blood sugar level input screen.
FIG. 26 is a flowchart of referencing an electronic medical record in the electronic medical record system.
FIG. 27 is an explanatory diagram of an electronic medical record screen for care of the electronic medical record system.
FIG. 28 is an explanatory diagram of a conventional medical chart.
FIG. 29 is an explanatory view of a conventional care chart.
[Explanation of symbols]
10: Electronic medical record system, 11: First building, 12: First medical facility, 13: First care facility, 14: Second building, 15: Second medical facility, 16: Third building , 17: Second care facility, 18: Server group, 19: Server room, 20: Medical server, 21: Care server, 22: Medical backup server, 23: Care backup server, 24: User identification Server, 24a: hub, 25: hub, 26: hub, 28: reception client, 28a: medical examination client group, 28b: examination client group, 29: internal medicine client, 30: cardiology client, 31: neurosurgery client, 32: respiratory client, 33: pediatric client, 34: rehabilitation client, 35: blood test client G, 36: urine test client, 37: X-ray test client, 38: ultrasound test client, 39: CT test client, 40: PWV test client, 41: bone density test client, 42: treatment Room client, 43: Pharmacy client, 44: Hospital ward client, 46: Hub, 49: Visiting nursing client, 50: Visiting care client, 51: Day care client, 52: Visiting rehabilitation client, 53 : Client for tsusho rehabilitation, 54: Client for group home, 55: Client for nursing home for the elderly, 55a: Client for rehabilitation center, 55b: Client for acupuncture, 55c: Client for pharmacy, 55d: Client for kitchen, 56 Hub, 57, 58: router, 59: hub, 60: reception client, 61: internal medicine client, 62: X-ray examination client, 63: pharmacy client, 65, 66: router, 67: hub, 68: Home-visit nursing client, 69: Home-visit nursing client, 70: Home-visit rehabilitation client, 71: Staff data storage, 72: Patient master data storage, 73: Dictionary data storage, 74: Staff rank classification, 75: Article data storage unit, 76: instruction data storage unit, 77: medical database storage unit, 78: medical data storage unit, 79: distribution unit, 80: distribution information storage unit group, 80a: examination information storage unit, 80b: outpatient Treatment information storage unit, 80c: Inpatient treatment information storage unit, 80d: Pharmacy information storage unit, 80e: Rehabilitation Information storage unit, 80f: acupuncture room information storage unit, 80g: kitchen information storage unit, 81: authority confirmation unit, 82: document issuing unit, 83: hospitalization management unit, 83a: reception data storage unit, 84: patient master data Storage unit, 85: dictionary data storage unit, 86: staff ranking unit, 87: article data storage unit, 88: instruction data storage unit, 89: care database storage unit, 90: care data storage unit, 91: sorting unit, 92: sorting information storage unit group, 92a: visiting nursing information storage unit, 92b: visiting care information storage unit, 92c: tsusho care information storage unit, 92d: visiting rehabilitation information storage unit, 92e: tsusho rehabilitation information storage unit, 92f: Group home information storage unit, 92g: Nursing care facility information storage unit, 92h: Rehabilitation center information storage unit, 92i: Acupuncture room information Storage unit, 92j: Pharmacy information storage unit, 92k: Kitchen information storage unit, 93: Authority confirmation unit, 94: Document issuing unit, 95: Entrance / exit management unit, 95b: Use patient data storage unit, 95c: Refer to medical data Authority confirmation unit, 96-98: patient, 99-101: electronic medical record, 102: PC password input screen, 103: electronic medical record system password input screen, 104: medical menu screen, 105: patient search screen, 106: Electronic medical chart screen for medical use, 107: patient information display section, 108: display menu section, 109: input menu section, 110: calendar display section, 111: data display section, 112: clinical test result screen, 112a: patient information section, 112b: Inspection result display section, 112c: Reference value display section, 112d: Selection section section, 112e: Print processing section, 113: Carte browse Screen, 113a: patient information section, 113b: article information display section, 113c: instruction information display section, 113d: date change section, 114: temperature reading list screen, 114a: time display section, 114b: result display section, 114c: graph Display unit, 114d: observation item display unit, 115: blood glucose level list screen, 115a: doctor instruction column, 115b: enforcement column, 116: CAPD drainage table screen, 116a: date display unit, 116b: CAPD treatment display unit, 116c : CAPD total amount display section, 117: medicine instruction input screen, 117a: patient information section, 117b: instruction item section, 117c: prescription medicine search section, 117d: prescription medicine information section, 117e: prescription medicine setting section, 117f: prescription instruction Content display section, 118: injection instruction input screen, 118a: patient information section, 118b: instruction item section, 118c: drug search section, 118d : Medicine information section, 118e: medicine setting section, 118f: injection and infusion instruction content display section, 119: radiological examination instruction input screen, 119a: patient information section, 119b: instruction item section, 119c: examination instruction search section, 119d: Test information section, 119e: Test content input section, 119f: Test supplementary instruction input section, 120: Clinical test instruction input screen, 120a: Patient information section, 120b: Instruction item section, 120c: Test instruction search section, 120d: Test information Section, 120e: examination content input section, 120f: examination supplementary instruction input section, 121: other instruction input screen, 121a: patient information section, 121b: instruction item section, 121c: instruction display section, 121d: instruction information section, 121e: Selection instruction display section, 121f: instruction content input section, 121g: selection content display section, 121h: supplemental instruction input section, 122: putter Instruction input screen, 122a: patient information section, 122b: instruction item section, 122c: pattern order display section, 122d: pattern order information section, 122e: selected pattern order display section, 122f: selected pattern order content display section, 123: critical Path input screen, 123a: patient information section, 123b: instruction item section, 123c: critical path display section, 123d: critical path information section, 123e: selected critical path display section, 123f: selected critical path content display section, 124: article Input screen, 124a: creation information section, 124b: patient information section, 124c: instruction item section, 124d: article classification section, 124e: input format selection section, 124f: article display section, 124g: reference material display section, 125: disease name Input screen, 125a: creation information section, 12 b: patient information section, 125c: disease information section, 125d: dictionary data reading section, 125e: disease name content display section, 125f: common recognition code display section, 125g: reference material display section, 126: temperature measurement result input screen, 126a: Time input section, 126b: doctor input section, 126c: result input section, 126d: observation item input section, 127: CAPD record input screen, 127a: time input section, 127b: doctor input section, 127c: result input section, 128: Blood glucose level input screen, 128a: time input section, 128b: doctor input section, 128c: result input section, 129: care menu screen, 130: care electronic medical chart screen, 131: patient information display section, 132: display menu section 133: input menu section, 134: calendar display section, 135: data display section

Claims (5)

A server that manages master data specifying a patient, and medical data of the patient and care data of the patient,
In cooperation with the server, a medical client capable of inputting the patient's medical data described in the master data arranged in a medical facility,
In cooperation with the server, having a nursing client that can be arranged in a nursing facility and input the nursing care data of the patient described in the master data,
An electronic medical record system wherein both the medical client and the nursing client can refer to the master data, medical data, and nursing data of the patient registered in the server. 2. The electronic medical record system according to claim 1, wherein the medical facility including the medical client and / or the care facility including the care client are provided at a plurality of locations. 3. The electronic medical record system according to claim 1, wherein the server has a medical server in which the medical data is stored, and a nursing server in which the nursing data is stored, and An electronic medical record system, wherein the master data having the same content is individually stored in each of the medical server and the care server. The electronic medical record system according to any one of claims 1 to 3, wherein the medical staff of the medical facility and the care staff of the nursing facility each have an individual identification code that identifies an individual to the server in advance. An electronic medical record system which is registered, and a range in which the data can be input and referred to is determined by the identification symbol. 5. The electronic medical record system according to claim 4, wherein the server has a personal identification server in which the identification symbol is registered.

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