JP4007821B2 - Disease name input device - Google Patents

Description

[0001]
BACKGROUND OF THE INVENTION
The present invention relates to a disease name input device.
[0002]
[Prior art]
Register medical treatment data such as treatments and medications performed on patients at medical institutions for each patient, and enter medical records based on the medical office calculators, medical treatments performed, medical treatments performed, medical records, etc. A medical data management system managed as a so-called electronic medical chart apparatus is becoming widespread.
[0003]
The medical institution creates a medical remuneration statement (hereinafter referred to as “receipt”) for the medical expenses, and bills the insurance institution for the remainder excluding the self-payment borne by the patient. When issuing a receipt, the medical office computer records the name of the patient's disease in the receipt along with the medical practice performed. In addition, since the electronic medical chart apparatus manages the conventional paper medical chart by replacing it with electronic information, the name of the patient's injury or illness is an indispensable item. Therefore, in these devices, medical practices such as examinations, treatments, injections, prescriptions, etc. performed by doctors on patients were input and stored as patient medical data, and these medical practices were caused. The name of injury is also entered and managed.
[0004]
Input of medical data occurs every time a medical examination is performed, and in addition, in order to prevent the patient from waiting in the window process, it is necessary to input a large amount of data at high speed. Therefore, since it is necessary to input medical data in a large amount and at a high speed as described above, it is common to input it with a code. For this purpose, there is provided a medical code master that registers the name, insurance score, and input code for each medical practice. And as for the disease name, the long disease name is not stored as it is, but is stored as a code in the same manner as the medical data. Therefore, a disease name code master in which a disease name and its code are registered is provided. Since the input of the injury / illness name does not occur so frequently, the input of the medical data and the input of the injury / illness name are performed on different input screens.
[0005]
[Problems to be solved by the invention]
Medical code masters and disease name code masters, in which standard contents are registered, are installed in the apparatus in advance and delivered to the user. In many cases, the standard content is sufficient, but in the case of a disease name in particular, depending on the specialty of the department or doctor, the disease name provided in the standard may not be covered. In view of this, an object of the present application is to provide a medical data management apparatus that can input not only a standard code but also a free text when inputting a disease name.
[0006]
[Means for Solving the Problems]
The present invention includes a disease name code master in which a disease name and its disease name code are registered, a disease name database that stores patient disease names in the disease name code, and a list of disease names registered in the disease name code master according to a predetermined classification. A disease name input device comprising a disease name input means for displaying a window for selecting and inputting the disease name, and a disease name registration means for storing the inputted disease name in the disease name database , wherein the disease name input means is selected from the list. The disease name selected by the user is separately displayed in the window as the first disease name described in the receipt and the second disease name different from the first disease name, and the second disease name is displayed as text in response to an instruction from the user. The disease name registration means stores the disease name code for the first disease name in the disease name database, and the edited first name is edited. And the text for the disease name of that second disease name is to store a predetermined code indicating that the text in the disease name database, is to solve the above problems.
[0007]
【Example】
FIG. 1 is a block diagram illustrating a configuration of an electronic medical chart apparatus 10 according to the embodiment. Reference numeral 11 denotes a control device constituted by a CPU, which reads out and executes programs and databases stored in the auxiliary storage device 16 and exhibits various functions as an electronic medical record. Reference numeral 12 denotes a display device composed of a CRT, 13 denotes an input device composed of a keyboard or a mouse device, 14 denotes a main storage device composed of a semiconductor memory, and 15 denotes a printing device. Reference numeral 16 denotes an auxiliary storage device composed of a hard disk device or the like, and stores the following program files and database files. That is, reference numeral 17 denotes a medical data input program, which is a program that accepts input of data related to a medical practice performed by a doctor on a patient and registers it in a medical database. Reference numeral 18 denotes a disease name input program, which is a program for accepting input of patient name data and registering it in the disease name database 20. Reference numeral 19 denotes a medical database, which stores medical data for each patient in a consultation unit. Reference numeral 20 denotes a disease name database, which stores patient injury and disease name data together with data such as a start date and an outcome date. Reference numeral 50 denotes a medical code master, which registers data such as the name and insurance points, together with the medical code, regarding medical practices that can be handled by the embodiment apparatus. The medical care database 19 stores this medical care code. Reference numeral 30 denotes a disease name code master, which registers names, classifications, and other data along with disease name codes for wound names that can be handled by the embodiment apparatus. The disease name database 20 stores this disease name code.
[0008]
FIG. 2 shows the record structure of the disease name database 20. This is to memorize the names of injuries and illnesses that have occurred in the medical institution since the patient first visited the hospital. Here, the receipt disease name code at the head of the record is a disease name code representing a wound disease name described in the receipt. The diagnosed disease name code is a disease name code that is specifically input when the doctor wants to assign a name of injury or illness different from the name of the received disease. Usually, the diagnosis disease name code includes the same code as the receipt disease name code. The start date is the date on which medical treatment for the disease name was started, the outcome and outcome date are the reason and date of termination or interruption of treatment, the next is the distinction between inpatient treatment or outpatient treatment, and the main disease name category is It is a classification of whether the disease name is the main disease name or not. The modifier code A to the modifier code D are supplementary explanations about the site and direction of the disease and are also input using codes registered in the disease name code master 30.
[0009]
When the doctor assigns a disease name different from the wound name prepared as standard in the disease name code master 30 to the diagnosis disease name text, since the code does not exist, the disease name is directly input as a character string, and the character string, that is, the text is stored. It is what. In addition, the comment text stores a comment made by the doctor for the disease name in the form of text, and the modifier text is a standard for one of the modifier codes A to D described above. When a doctor adds a modifier that is not provided in the code, the text is stored. In the embodiment, each of these texts is stored up to 25 characters.
[0010]
FIG. 3 shows the record structure of the disease name code master 30. This is a subset extracted from the full set of all wound disease name codes according to the specialty and request of the medical institution, and the one created and installed in advance by the manufacturer is stored in the user. This is because the processing speed is faster than searching a full database. Here, the receipt disease name code at the head of the record is a 6-digit code that can be used by the user when inputting the disease name, and the standard disease name code is a standard code in a full set of disease name masters. The name is the name of the wound or illness written in kanji, and the reading is Kyomi Yomi. The standard classification represents the classification of the name of the disease.
[0011]
Next, the operation of inputting the name of injury and illness in the embodiment will be described. When the user instructs the start of disease name input, the control device 11 reads out and executes the disease name input program 18 from the auxiliary storage device 16 and displays the wound name input window 40 shown in FIG. This is for entering the name of the patient's injury or illness. Since the disease names are sorted and displayed in a list in the order of the Japanese syllabary, a row including a desired disease name reading is first selected. Then, a list of disease names classified in the row is displayed in the right column 41. The figure shows a state where “Ta line” is selected. Therefore, the user scrolls the list to search for a disease name, places the mouse cursor on the desired disease name, and double-clicks. Thereby, the disease name is displayed in the column of the diagnosis disease name 42 and the receipt disease name 43 in the input injury name column below. At this time, the same disease name selected above is displayed in the diagnosis wound name 42 and the receipt disease name 43.
[0012]
Then, this disease name is displayed in the patient history column 45 on the lower side of the window by instructing the registration button on the lower right with the cursor. Thereafter, if the OK button is indicated, the contents of the patient history column 45 are registered in the patient's disease name database 20. At that time, the control device 11 adds the contents up to the comment 46 after the start date on the right side of the window and the contents from the prefix to the suffix, that is, the contents shown in FIG. It is registered in the database 20. As shown in FIG. 2, the disease name registered in the disease name database 20 is not the disease name displayed on the screen itself, for example, “first color blindness”, but a 6-digit received disease name code read from the disease name code master 30. . Usually, the same code is registered in the receipt disease name code and the diagnosis disease name code of the disease name database 20 shown in FIG.
[0013]
Here, the comment 46 registered in the database together with the disease name code can be input free text on the window in the embodiment. When the cursor is moved to the comment input field 46 of the window 40 and a character string is directly input, the control device 11 registers in the disease name database 20 as described above. In the embodiment, up to 25 characters can be input and registered in the database.
[0014]
In the embodiment, the diagnosis and injury name 42 can be directly input by free text instead of the code. Therefore, the user designates the edit mark 44 at the right end of the diagnosis / sickness name column 42. In response to this, the control device 11 displays a cursor for inputting characters in the same field 42 and allows the input of text. The control device 11 registers the input character string in the disease name database 20 as the diagnosis disease name text shown in FIG. In that case, a special code indicating text input is registered in the diagnosis disease name code. Even in this case, since the original code input is alive for the name of the disease, the standard disease name is described in the receipt.
[0015]
Similarly, one of the modifier code A to the modifier code D shown in FIG. 2 is allowed to input free text instead of a code. The prefix, part, direction and suffix on the right side of the window 40 correspond to this. When the user points the edit mark 47 at the right end of the input column with the mouse device, the control device 11 displays a cursor for character input in the same column accordingly, so that characters may be directly entered in the respective input columns. . The input character string is registered in the disease name database 20 by the control device 11 as the modifier text shown in FIG. Then, a special code indicating text input is registered in the corresponding modifier code. In the embodiment, the diagnosis disease name text and the modifier text can be inputted and registered up to 25 characters.
[0016]
As described above, in the embodiment, even when a disease name other than the wound name prepared as a standard is desired, it can be entered and registered in the form of free text. In addition, modifiers such as prefixes, parts, and directions that qualify disease names can be entered in the database together with disease names by entering free text, and free text comment data can also be registered with disease names. is there.
[0017]
【The invention's effect】
According to the present invention, it becomes possible to input and register disease names other than the injury and illness names prepared as standard in the form of free text, and it becomes possible to give more detailed disease names according to the specialty of a medical institution or doctor. Also, modifiers such as prefixes, parts, and directions that modify disease names can be entered in the database together with the disease names by entering free text, so that finer settings can be made according to the doctor's idea. In addition, since free text comment data can be registered with the disease name, a simple explanation of the disease name can be left.
[Brief description of the drawings]
FIG. 1 is a block diagram illustrating a configuration of an embodiment.
FIG. 2 is a diagram showing a record configuration of a disease name database according to an embodiment.
FIG. 3 is a diagram showing a record configuration of a disease name code master according to an embodiment.
FIG. 4 is a diagram showing a display example of a sickness name input window in the embodiment.
[Explanation of symbols]
DESCRIPTION OF SYMBOLS 10 Electronic medical record apparatus 11 Control apparatus 12 Display apparatus 13 Input apparatus 14 Main storage apparatus 15 Printing apparatus 16 Auxiliary storage apparatus 17 Medical treatment input program 18 Disease name input program 19 Medical treatment database 20 Disease name database 30 Disease name code master 50 Medical treatment code master 40 Wound and disease name input Windows

Claims (3)

A disease name code master in which a disease name and its disease name code are registered, a disease name database for storing a patient's disease name as the disease name code, and a list of disease names registered in the disease name code master are displayed according to a predetermined classification, and the user is allowed to select and input A disease name input device comprising disease name input means for displaying a window for the disease and disease name registration means for storing the input disease name in the disease name database , wherein the disease name input means is selected by the user from the list The first disease name described in the receipt and the second disease name different from the first disease name are separately displayed in the window, and the second disease name can be edited by the user as text in accordance with an instruction from the user. The disease name registration means stores a disease name code for the first disease name in the disease name database, and the edited second disease name is stored in the disease name database. There are its text, disease name input device second disease name is characterized in that to store a predetermined code indicating that the text in the disease name database. The disease name input means displays a comment input field for the user to enter text in the window, and the disease name registration means stores the text in the comment input field in the disease name database in association with the selected disease name. The disease name input device according to claim 1 . In the disease name code master, a modifier to be added to the disease name and its modifier code are further registered. The disease name input means displays the modifier in a list so that the modifier can be selected and input. The disease name registration means selects the disease name. The disease modifier is associated with a disease name and stored in the disease name database, the disease name input means displays the selected modifier as a text editable according to a user instruction, and the disease name registration means The disease name input device according to claim 1 or 2, wherein the edited text is stored in the disease name database as modifier data.

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