JP2000148877A - Clinical recording preparation supporting device - Google Patents

Abstract

PROBLEM TO BE SOLVED: To automatically record a disease name corresponding to a treatment in a clinical recording by retrieving a treatment-to-disease name storing means based on stored treatments and reading disease name candidates estimated from the treatment. SOLUTION: The data of a clinical recording to be used to decide a disease name from a clinical recording file 14, and a treatment-to-disease name table of a hard disk 13 is retrieved with registered treatment contents as an index. When a disease name candidate corresponding to a treatment exists, the disease name candidate is once registered with the diseased name field of a clinical recording. In such a case, when plural disease name candidates exist, all of the extracted disease name candidates are once registered with the disease name field. Then, an inappropriate disease name has only to be eliminated among the registered disease names to make it convenient to prepare a clinical recording. When no disease name candidates exist, a disease name is not registered with the disease name field but disease name decision processing is carried out according to an operator's instruction.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to an apparatus for supporting the preparation of medical records, so-called medical records, recorded by doctors. In particular, the present invention relates to an apparatus suitable for supporting creation of a dental chart.

[0002]

2. Description of the Related Art To explain dental treatment as an example, when a dentist treats a patient, the contents of the treatment are recorded in a dental chart for each patient.

[0003] In dental care, medical examination and treatment are performed almost simultaneously, and necessary treatment is performed while looking into the oral cavity of a patient who is lying on his / her back on a medical table.
Patients must keep their mouth wide open during medical treatment, and continuous medical treatment for a long time is painful for patients. Therefore, medical treatment is performed skillfully and quickly, and one medical treatment time for one patient is usually about 30 minutes to 1 hour.

[0004] Further, in order to reduce the waiting time of a patient who visits a clinic, a clinic time is generally reserved. Appointment can be made, for example, by taking into account
Accepted in units of 5 to 20 minutes. Therefore, the dentist during the consultation time has to carry out the treatment of the patient one after another, and is very busy.

[0005]

In the current state of such dental care, a dentist is required to make a
There is no time to slowly record medical treatments and disease names in dental charts.

[0006] In other words, the dentist must record the contents of the medical treatment on the dental chart in the meantime while treating many patients one after another. Therefore, the emergence of a mechanical system that supports the creation of records of dental charts has been desired. The troublesomeness of the chart creation work is not limited to dentistry, but also applies to other medical fields such as surgery, internal medicine, and otolaryngology. In any medical field, the number of medical records increases with the number of patients. Therefore, there is a demand not only for creating medical records but also for efficiently storing and managing the medical records.

The present invention has been made in view of the above background, and a main object of the present invention is to create and manage a chart that can reduce the time and effort required for creating and managing a chart by using a computer system. To provide a support system.

[0008] A specific object of the present invention is to provide a chart creation support apparatus in which, when a specific treatment is recorded in a chart, a disease name corresponding to the treatment is automatically recorded.

[0009]

SUMMARY OF THE INVENTION The present invention provides a method for storing a plurality of treatments and a candidate for a disease name predicted from each treatment. Treatment storage means for storing the treated treatment, reading means for searching the treatment versus disease name storage means based on the treatment stored in the treatment storage means, and reading out a disease name candidate predicted from the treatment; Holding means for holding the disease name candidate read by the means as a disease name to be recorded in the medical record, wherein the reading means, when a new treatment is additionally stored in the treatment storage means, the additionally stored treatment Based on a plurality of treatments, the treatment-disease name storage means being searched, and a disease name candidate that satisfies all treatments being read out. By the candidate, and wherein the retained Disease is intended to be updated is a chart creation support apparatus.

[0010]

According to the first aspect of the present invention, a candidate for a disease name is automatically recorded by recording the contents of treatment in a medical chart. Therefore, it is only necessary to delete an inappropriate disease name from among the recorded disease name candidates, which makes the chart creation convenient. In particular, in dental care, the treatment content usually has priority over the disease name, and when the treatment content is determined, the disease name is automatically determined. Therefore, by recording the treatment actually performed in the medical chart, the name of the disease is also automatically recorded, making the medical chart creation convenient.

[0011]

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS An embodiment in which the present invention is applied to a dental chart preparation support apparatus in a dental office will be described in detail below. FIG. 1 is a diagram illustrating an outline of a hardware configuration of a system according to the embodiment. This system includes a reception CPU 1 and a medical office CPU 2, both of which are mutually connected by a signal line or the like. A so-called personal computer can be used as the reception CPU 1 and the examination room CPU 2. In this embodiment, the reception CPU 1 is set as a host and the examination room CPU 2 is set as a terminal.
How to set these hosts and terminals is arbitrary,
The reception CPU 1 may be a terminal, and the examination room CPU 2 may be a host.

The reception CPU 1 has a keyboard 3 for inputting various data and operation signals, a display 4 for displaying file contents and various data, and a printer 5 for printing charts, bills and the like. Is connected. As the keyboard 3 functioning as a data input device to the reception CPU 1, a keyboard having various keys such as character data input keys, numerical data input keys, function keys, and command keys is used. Preferably, it is convenient if an input unit such as a handwriting input unit or a so-called mouse is provided.

As the display 4, a CRT display or a liquid crystal display can be used. Preferably, a transparent so-called touch switch sheet is arranged on the display surface of the display 4 and data can be input from the touch switch sheet 6 as well. The printer 5 is preferably an electrophotographic laser printer capable of recording not only characters and numerical values but also a picture (graphic) described later. The work memory 7 necessary when the CPU 1 executes a processing operation is connected to the reception CPU 1.

A keyboard 8, a display 9 having a touch switch sheet 11, a printer 10, and a work memory 12 are also connected to the medical office CPU 2. The configurations, functions, and the like of the keyboard 8, the display 9, the printer 10, and the work memory 12 are the same as those connected to the above-described reception CPU 1. The reception CPU 1 is further connected to a hard disk 13 for storing necessary data and a floppy disk drive 14 for storing a chart file to be described later.

The data stored in the hard disk 13 includes various data files and correspondence tables. Data files include menu screen files, visit registration files, site registration files, treatment selection files, checkout files, X-ray screen files, anesthesia screen files, oral surgery screen files, prosthetic screen files, medication screen files, and vertical expansion of teeth. It includes a picture file, a left and right development picture file, and a denture picture file. The correspondence table includes a treatment-to-disease name table that represents the correspondence between treatments and disease names, and a medical treatment-to-score table that represents the relationship between medical treatment contents and scores determined by insurance medical care regulations.

A floppy disk is mounted on the floppy disk drive 14, and the chart data is stored in the mounted floppy disk. By storing the chart data on a floppy disk, it is possible to cope with an increase in the number of patients. In addition, if the medical record data is stored in a different floppy disk for each patient type (for example, an insurance medical care patient, a non-insurance medical care patient, a male patient, a female patient, an adult patient, a pediatric patient, etc.), management is convenient.

In the system of this embodiment, as described above, the reception CPU 1 functions as a host. Therefore, when the examination room CPU 2 accesses the hard disk 13 and the floppy disk of the floppy disk drive 14, the reception CPU 1 Do through. The hardware configuration of the system shown in FIG. 1 is merely an example, and for example, a hard disk or another memory device may be connected to each of the CPUs 1 and 2, or another configuration may be adopted.

FIG. 2 is a developed view showing the relationship between a plurality of data files stored in the hard disk 13.
The plurality of data files are arranged in a hierarchical structure so that the CPUs 1 and 2 can easily access them. In particular,
The menu screen file is positioned as the top-level file. By opening the menu screen file, the visit registration file, the part registration file, the treatment selection file, and the settlement file can be read. Further, when the treatment selection file is opened, the X-ray screen file, the anesthesia screen file, the oral surgery screen file, the prosthetic screen file, and the medication screen file can be selectively read. Further, the oral surgery screen file is provided with upper and lower developed image files of teeth and left and right developed image files as lower-level files. The denture picture file is provided in the prosthetic screen file.

Next, among the data files, the contents of the files related to the features of this embodiment will be described with reference to specific examples. FIG. 3 shows the contents of the menu screen file. When the menu screen file is opened, the contents of FIG. 3 are displayed on the display. In other words, “visit registration, site registration, treatment selection, settlement” is displayed. When a desired display content is selected by an operator or a dentist, a file of the content is opened next. The selection of the display content is performed, for example, by moving a cursor displayed on the screen to a desired display content, pressing a predetermined key of a keyboard, or clicking a mouse button. Alternatively, as described above, the display 4,
In the case where the touch switch sheets 6 and 11 are provided on the display surface of No. 5, the content may be selected by pressing on the desired display content.

FIG. 4 shows the contents of the treatment selection file. When the treatment selection file is read from the hard disk 13 and opened, the contents of FIG. 4 are displayed on the display.
The treatment selection file lists a plurality of treatments performed in the dental office. That is, “examination, X-ray, anesthesia, filling, endodontic treatment, periodontal treatment, oral surgery, prosthesis, addition, guidance, home medical treatment, medication” is displayed. These treatments are examples, and treatments other than the treatments described here may be included.

FIG. 5 shows the contents of the X-ray screen file. This file contains, for example, “simple imaging” and “tomography”, and specific imaging items are represented so that more detailed content selection can be made for each imaging. FIG. 6 shows the contents of the anesthesia screen file. In the anesthesia screen file, the type of anesthesia, for example, “transmission anesthesia”, “infiltration anesthesia”
"Compression anesthesia" and the anesthetic used for each anesthesia are displayed. The dentist or the like looks at this screen and selects an anesthetic and an anesthetic suitable for the patient.

FIG. 7 shows the contents of the oral surgery screen file. In the oral surgery screen file, oral surgical procedures performed in a dental clinic or the like are listed. These procedures preferably include all oral surgery procedures required at dental clinics and the like. Further, in the oral surgery screen file, although not displayed in addition to the display contents of FIG. 7, a specific surgical procedure for each treatment is also registered. For example, taking the procedure of "impact extraction" as an example, the corresponding technique of "dislocation removal with a trocar after crown division and buccal alveolar bone removal" is registered. Therefore, as will be described later, when "impacted tooth extraction" is selected as the treatment, "impacted tooth extraction" is recorded in the medical record, and at the same time, the above-mentioned operative procedure corresponding to the treatment is also recorded.

FIG. 8 shows the contents of the prosthetic screen file.
“Prosthesis” is a procedure for handling so-called dentures (dentures). In the prosthetic screen file, treatments for treating dentures are listed, and a treatment performed on the patient is selected from the treatments. FIG. 9 shows the contents of the medication screen file. The medication screen file contains a list of medicines necessary for treatment. The medicine list is organized by use or effect, and the amount of use at one time is also recorded.

When each of the above screen files is displayed on the display, if the file content is large, it may not be displayed on the display at once. In such a case, the display content of the display may be scrollable, for example. FIG. 10 shows the contents of the up-and-down developed picture file of the tooth. The picture inside the center frame in FIG. 10 is the picture registered in the file. Since the number and arrangement of the teeth of an adult are fixed, a picture of the teeth arranged in the upper jaw and a picture of the teeth arranged in the lower jaw are shown in an expanded view. One of the features of this embodiment is that a file in which such a picture is stored is provided in advance, and a necessary part of the picture can be read out when a dental chart is created, as described later. .
That is, when recording the oral surgery procedure, a picture including the tooth to be treated is read. In this embodiment, four parts are read out selectively: the right half of the upper jaw, the left half of the upper jaw, the right half of the lower jaw, and the left half of the lower jaw.

FIG. 11 shows the contents of the left and right developed picture file of the tooth. In this file, a picture in which the teeth are developed in a so-called panoramic shape from left to right as shown in the figure is registered. When recording oral surgery on dental charts,
The two teeth before and after that are read out in principle. In the case of so-called unfamiliarity, since it is the extreme end, it does not correspond to two front and rear teeth.

In FIG. 11, the picture in the center frame is the picture registered in the file, and as shown by the dashed arrow,
When the tooth to be treated is designated, the tooth to be treated and the two teeth before and after it are read from this file, displayed, and recorded in the dental chart. Although the file data of the tooth pictures in FIGS. 10 and 11 are shown only for adults, it is preferable that the tooth pictures of children are also registered as file data.

When preparing a dental chart, it is necessary to show the teeth to be subjected to oral surgery and the teeth in the vicinity thereof, and to show what kind of treatment was performed. However, it takes time and trouble to write the treatment target tooth and the teeth before and after it in the medical chart each time. Therefore, in this embodiment, as will be described in detail later, a picture of a tooth is registered in a file in advance, and the dental surgery target tooth and the teeth before and after it are automatically read out and recorded in the medical record. I did it. By doing so, the dentist or the like only needs to write, for example, the patient's symptoms, incision lines, suture lines, and the like in the displayed tooth picture, and it is very easy and short to create a chart including the tooth picture. Can be done in time.

FIG. 12 shows a part of the contents of the denture picture file. The "prosthetic" procedure requires a denture. By displaying what the denture is and what adjustments have been made to the denture on the chart, the contents of the medical treatment will be clear forever. Writing a denture picture on a medical record is a relatively cumbersome task. Therefore, in this embodiment, a denture normally used is registered in a file in advance, and a picture of the denture to be used can be read from the file as needed.

In the denture picture file, more denture pictures are actually registered in the file. FIG.
Shows a part of the treatment versus disease name table stored in the hard disk 13. A characteristic of dental care is that the correspondence between treatment and disease name is clear. That is, if the name of the disease is known, the treatment for the disease name is determined. Conversely, this means that knowing what kind of treatment has been performed on a certain patient allows the patient's disease name to be known. Therefore, when the dentist decides on the treatment, it is preferable that the medical record creation support can be performed so that the disease name corresponding to the treatment is automatically entered in the medical record. In the system of this embodiment, when the treatment is specified, the disease name is automatically recorded in the medical record. As the data necessary for this, a treatment versus disease name table shown in FIG. 13 is registered in the hard disk 13 (see FIG. 1).

FIG. 14 shows a part of the medical treatment score table. In the case of insurance medical treatment, a dentist or the like must submit a medical fee statement to a prescribed insurance institution and charge insurance medical treatment costs. It is necessary to enter the points defined in the insurance medical care regulations in this medical fee statement for each medical treatment. The preparation of the medical remuneration statement is complicated, and if there are any omissions in the points, the appropriate medical insurance remuneration will not be returned. Therefore, in this embodiment, at the time of creating a medical record, the score for each medical treatment is recorded, and the medical treatment fee statement can be almost automatically created based on the medical record data. The medical treatment score table shown in FIG. 14 is stored in the hard disk 13 in advance as data necessary for that.

Next, various operations of the system shown in FIG. 1 will be described with reference to flowcharts showing processing contents. FIG. 15 shows a flowchart of the visit registration processing. When a patient comes to the hospital, registration of the patient's visit is performed at the reception. This registration is performed by the reception operator from the keyboard 3 connected to the reception CPU 1. About this visit registration process, FIGS.
This will be described with reference to FIG.

In this process, “visit registration” is selected from the menu screen displayed on the display 4. Then, the visit registration file among the data files on the hard disk 13 is read by the reception CPU 1, and a selection screen for new patient registration or re-examination registration is displayed on the display 4 (step S11). The reception operator selects the display of “new patient” displayed on the display 4 with a cursor, for example, when the patient is a new patient, and selects the re-examination display with the cursor when the user is “recheck”. In response to this, the reception CPU 1
Thus, it is determined whether the input is a new patient input or not (that is, a re-examination input) (step S12).

If the input is a new patient input, a screen for registering patient data is displayed on the display 4. The reception operator inputs the name of the examinee (patient name), date of birth, address, insurance card number, insurance type, etc. from the keyboard 3 according to this display screen. When the data input is completed, the reception CP
By U1, the input patient data is registered and chart data is created (step S13). At this time,
In the medical record data, "first consultation" is recorded as a medical record, and in the case of insurance medical treatment, the first consultation score is recorded (steps S14 and S17). Specifically, the reception CPU 1 searches the medical care score table recorded on the hard disk 13 and reads out the score of “first consultation”. Then, the read score is recorded in association with the “first consultation” of the chart data.

On the other hand, if it is determined in step S12 that the patient is not a new patient, that is, it is determined that the patient is to be re-examined, the medical record data of the visiting patient should be retrieved from the medical record file and read. Is performed (step S15). Then, the date of the visit and “re-examination” are recorded in the medical record data. Further, the medical treatment score table of the hard disk 13 is searched, and the re-examination score is read out.
This is recorded in the chart data (steps S16, S
17).

Thereafter, the medical record data of the new patient and the re-examination are stored in the work memory 7 because they are used for treatment (step S18). next,
The part registration will be described according to the flow of FIG.
“Registration” is a process of recording a treatment target location in a medical chart. Normally, site registration is performed based on an interview or confirmation of the state of the oral cavity when a dentist starts medical treatment of a patient.

The dentist or the like who has grasped the treatment location operates the keyboard 8 and selects "Registration" on the menu screen (see FIG. 3). In response to this, the clinic room CPU 2 reads the site registration file from the data file of the hard disk 13 via the reception CPU 1. Then, a part disease name input screen is displayed on the display 9 (step S21).

This screen is, for example, a screen as shown in FIG. That is, it includes a site, a disease name, a medical treatment start date, a medical treatment end date, and a tooth arrangement diagram, and a number (or code) for specifying each tooth is written in the figure. The dentist or the like enters the treatment target tooth at the “site” on the site disease name input screen displayed on the display 9 using the number (or code) shown in the tooth arrangement diagram.

FIG. 23 shows an example of entry of a part. FIG.
(A) shows that the 8th tooth on the right side of the lower jaw (so-called ignorance) is to be treated. FIG. 23B shows that the second tooth (side incisor) of the upper jaw is to be treated. FIG. 23 (c) shows that 14 teeth from the upper right 7th to the left upper 7th are to be treated. FIG.
3 (d) is “7, 6, 5, 4” on the left and right of the lower jaw, respectively.
Indicates that the target tooth is to be treated.

As described above, in the region registration, the tooth to be treated is specified by writing the tooth number in each quadrant divided into four quadrants by a cross line. This is a convention in dental charts. In addition, in the arrangement diagram of FIG. 22, teeth A to E shown on the inside represent milk teeth, and when treating milk teeth of infants and the like, the parts are specified by reference signs A to E. Done.

Referring back to FIG. 16, the input of the part for specifying the tooth to be treated is performed by, for example, the keyboard 8. When a part is input from the keyboard 8, the medical office CPU 2 determines that there is a part input (step S22). Then, the input part is registered as medical record data (step S23). Further, the medical treatment start date is automatically registered by the CPU 2 (step S24).

Next, the treatment selection process will be described. In the practice of dental care, in the case of a new patient, after the site registration, an X-ray photograph of the teeth is taken, and the treatment content is determined with reference to the X-ray photograph. Then, anesthesia is given to the treatment site, and treatment, that is, oral surgery is performed. Alternatively, dentures are made that fit the patient's mouth. Then the necessary medicine is given to the patient. In parallel with the treatment, the dentist records a medical record on a medical chart.

Next, a procedure for creating a medical record of a medical chart by the apparatus according to this embodiment based on a specific medical example will be described. The description is based on four specific cases. Case 1: Extraction of the third lower molar of the right lower jaw (extraction of the lower right unidentified parent) Case 2: Removal of the root cyst of the right incisor Case 3: Installation of a complete denture Case 4: Installation of a free denture First, Case 1 An example will be described.

In the case 1, the contents of medical treatment recorded in the medical chart are, for example, the contents shown in FIG. That is, April 1
On April 4, a first consultation was received, and after X-ray photography, anesthesia and gingival incision were performed to extinguish the swelling of the gums, and predetermined drugs were delivered. On April 18, a re-examination was accepted, and unexplained tooth extraction embedded in the gums, that is, impacted tooth extraction was performed. And the prescribed medicine is handed over. The patient was re-examined on April 19, the following day, and the cleaning and the subsequent progress were examined. The treatment for Case 1 has been completed.

Using the system of this embodiment, FIG.
The medical treatment record of the medical record shown in FIG. In particular, the tooth pictures of April 14 and of April 18 are also automatically recorded with the aid of a computer device. Therefore, the dentist or the like can easily and easily record the medical treatment contents in the patient's medical record while performing medical treatment. In particular, the picture of the tooth is automatically recorded,
It is possible to clearly indicate what kind of treatment was specifically performed.

Hereinafter, the method of creating the chart data will be specifically described according to the flow of the procedure of the treatment selecting process shown in FIGS. 17 to 19, while referring to the contents of the chart shown in FIG. When “treatment selection” in the menu screen displayed on the display 9 is selected, the treatment selection file is read from the data file on the hard disk 13 by the medical office CPU 2 and the display 9 is displayed.
Is displayed (step S31). This treatment selection screen is a screen listing a number of treatments shown in FIG. The dentist or the like selects a treatment performed on the patient (or a treatment to be performed) from the treatments. In this example,
First, “X-ray” is selected. The selection operation is performed using the keyboard 8 as in the other operations.

When the treatment room CPU 2 determines that a treatment selection signal has been input (step S32), the selected X-ray screen file is read from the data file on the hard disk 13 in accordance with the inputted treatment selection signal. (Step S33). Then, it is displayed on the display 9 (step S34). This display screen has the contents shown in FIG. 5 described above. A dentist or the like selects an imaging method from the X-ray screen file. For example, a “panoramic X-ray photograph” (so-called panoramic photograph) for tomography and a “standard type” (so-called dental photograph) for simple photographing are selected. This selection is also performed using the keyboard 8.

When the input of the selection signal is determined by the medical office CPU 2 (step S35), the contents of the selected treatment, that is, the selection of the panoramic photograph and the dental photograph in this case, are displayed on the display 9 (step S35). S3
6). The selected content is registered in the work memory 12 as chart data (step S37). If the dentist wants to change the selected content or selects an erroneous procedure, the dentist inputs a cancel signal using the cancel key on the keyboard 8, for example. On the CPU2 side,
When this cancellation input is determined (step S38), the treatment registered in step S37 is canceled (step S39),
Returning to step S34, the contents of the X-ray screen file shown in FIG.

Next, proceeding to FIG. 18, if there is no cancellation input or the like, the hard disk 1 is
3 is searched (step S4).
0), points corresponding to the contents registered in step S37 are read. That is, if there is a score corresponding to the content registered in the work memory 12 in step S37, the score is recorded in association with the registered content (step S4).
1, S42). If no insurance score is set in the registered content, the score registration process in step S42 is not performed.

Thereafter, in step S43, it is determined whether or not the content registered in step S37 is an oral surgery procedure. In this example, since X-ray imaging has been registered, NO is determined in the step S43, and the process proceeds to the step S46. In step S46, it is determined whether the registered content is a prosthetic treatment. Also in this determination, since the determination is NO, the process proceeds to step S50 in FIG.

In step S50, the registered contents stored in the work memory 12 are displayed on the display 9. This display is the part of A in FIG. The dentist or the like who has confirmed the registered contents by the display inputs a confirmation signal from the keyboard 8. The presence of a confirmation signal is determined by the examination room CPU 2 (step S52). Next, an inquiry as to whether or not to print the chart is displayed on the display 9 (step S52). At this stage, since chart printing is not performed, the process waits for a signal input indicating that chart printing is not performed (step S53). Then, the process returns to step S31 in FIG.

In step S31, the procedure selection screen shown in FIG. 4 is displayed again, and "anesthesia" is selected as the next procedure. In response to this selection, the clinic room CPU 2 reads the anesthesia screen file from the hard disk 13 and displays the contents on the display 9 (steps S32 and S32).
33, S34). This display screen is, for example, the content shown in FIG. 7, and the dentist or the like selects the content of anesthesia given or to be given to the patient from among them. In this example, “infiltration anesthesia” is selected, and “xylocaine” is selected as an anesthetic. In response to this, the medical office CPU 2
The selected content is displayed on the display 9 (step S36), and the selected content is registered in the work memory 12 (step S37). The display content is the content of B in FIG. If there is no cancellation input, a score corresponding to the registered content is retrieved from the medical treatment score table, and the score is also registered in the work memory 12 (steps S40 to S40).
S42).

In this case as well, since the registered contents are neither the oral surgery procedure nor the prosthetic procedure, the processing in the medical office CPU 2 is performed in steps S43 → S46 → S50 → S51 → S
It proceeds to 52 → S53 → S31. In the next treatment selection, "oral surgery" is selected from the treatment selection screen shown in FIG. 4, and for example, a screen shown in FIG. 8 is displayed (step S).
31, S32, S33, S34).

The dentist or the like selects a treatment performed on the patient or a treatment to be performed from the various treatments listed on the oral surgery screen, that is, “incision (gingival)” in this example. The selected treatment is displayed in step S36 and registered in step S37 in the same manner as described above. Also,
The score corresponding to the selected treatment is read, and the score is also registered (steps S40 and S42).

Next, in step S43, it is determined whether or not the registered content is an oral surgery procedure. In this case, since it is an oral surgery, the processes of steps S44 and S45 are executed. That is, in the case of the oral surgery, the “part registration data” previously registered as the chart data is read (step S44). In this example, the part registration data has the contents shown in FIG. Based on the read-out part registration data, it is specified which part is involved in the oral surgery. As a result, a corresponding partial picture is read from the upper and lower developed picture file of the tooth and / or the left and right developed picture file of the tooth recorded on the hard disk 13. Specifically, the picture of the tooth on the right side of the lower jaw is read out of the vertically expanded picture file of the tooth shown in FIG.
Also, from the left and right developed picture file of the tooth shown in FIG. 11, a picture of two teeth before and after the tooth with the number 8 designated by the region registration as the center is read. However, in this example, since the tooth registered as the part is the eighth tooth and is the end tooth, the tooth and the previous three teeth are read out.

The read partial tooth picture is displayed together with the chart data registered in steps S37 and S42 (step S50). The dentist or the like looks at the displayed contents, deletes unnecessary pictures, and adds necessary symptoms and details of treatment. The display after the contents have been added is the part C in FIG. In this display, the swelling (+) and tenderness (+) and the location thereof are added to the vertical development image of the tooth. Also, an incision line made to produce pus is added.

It is preferable that the patient's symptoms, treatment lines, and the like added in connection with the displayed picture are added by handwriting while looking at the picture displayed on the display 9. For example, if the keyboard 8 has a handwriting input function, the patient's symptoms, treatment lines, and the like can be written by handwriting input. Alternatively, when a transparent touch switch sheet 11 is disposed on the surface of the display 11, writing can be performed using the sheet 11.

Thereafter, when the content of the oral surgery is confirmed, the process proceeds to steps S52 → S53 → S31 again, and then the content of the medication is recorded in the medical chart. That is, the medication screen file is read in step S33, and the screen is displayed on the display 9 (step S34).
The medication screen is, for example, the screen shown in FIG. 9 and includes a medicine list. The dentist or the like selects a medicine from the medicine list. In response to this, the medicine selected by the CPU 2 is registered (step S37), the score of the registered content is also registered (step S42), and the registered content is displayed on the display 9.
Is displayed (step S50). This display is the content of D in FIG. The dentist or the like sees this display and adds the necessary amount of medicine to be given to the patient on that day.

When the recorded contents are finally confirmed, the processing is completed, and the chart data is stored on a floppy disk. In the above description, the contents displayed in step S50 are the part A and the part B of the data of April 14 in the medical treatment contents of the medical chart of FIG.
, C and D are displayed. However, when the part A is displayed instead of such a display, the “first consultation” recorded before that is displayed.
170 "may be displayed together. Similarly, when the part B is displayed, the parts E and A may be displayed together. Further, when the part C is displayed, the parts E, BA, and B may be displayed together. Further, when the part D is displayed, the parts E, A, B, and C may be displayed together.

As shown in step S53 of FIG. 19, it is preferable that a chart print signal can be input. When the input of the chart print signal is determined in step S53, the printer 10 is driven by the CPU 2, and the chart contents are set on the chart sheet set in the printer 10.
That is, the record of April 14 in FIG. 24 is printed. The printed matter may be stored as a medical chart.

If the system does not have a handwriting input function or the like, the symptoms and treatment lines to be added to the partial pictures of the teeth may be handwritten by a dentist or the like on a printed paper chart. In addition, the amount of medicine and the like in the medication record may be manually written in the medical chart. In this case, the chart is stored as an original, and the next time the patient returns to the hospital for examination, the chart is set on the printer 10 and the contents after April 18 are additionally printed on the chart. What should I do?

The medical record on April 18 shown in FIG. 24 is recorded in substantially the same manner as the medical record on April 14 described above. In brief, “re-examination 32” is recorded by the visit registration process shown in FIG. Also, FIGS.
In the treatment selection process shown in (1), “transmission anesthesia” and its score “38 + 9” are recorded based on the anesthesia screen file.
In addition, based on the oral surgery screen file, “impact extraction” and its specific content “dislocation removal with a coultrus after crown division and buccal alveolar bone deletion” are recorded, and the score “1”
000 "is recorded. Also, the partial picture of the tooth shown in the record on April 18 in FIG. 24 is automatically recorded.

The dentist or the like may add the contents of the treatment, such as the suturing line and the removed portion, and the treatment contents of "3 sutures" to this picture. The record for the medication on April 18 is made as for April 14.
Further, the recorded contents on April 19 in FIG. 24 will be described. The contents for April 19 are re-examination and cleaning. The irrigation is selected from the oral surgery screen file. When "wash" is selected, the contents shown in FIG. 24, that is, spontaneous pain (), percussion pain (), and the like are automatically displayed. The dentist or the like examines the patient's symptoms and, if the patient complains of any of the indications shown here, additionally writes a + sign in parentheses.

Next, the case 2 will be described. Case 2
Is the process of removal of the root cyst in the upper right incisor. 4
On the 22nd of the month, a first consultation, a score of “170” and a region registration are performed. In this case, the part registration of FIG. 23B is performed. Then, the content and score of the X-ray photography are registered, and "incision (periosteum)" of infiltration anesthesia and oral surgery is registered. In connection with the registration of this oral surgery procedure, as shown in FIG.
Centered on the 2nd tooth in the upper right jaw, which is the tooth to be treated
The teeth are read and registered from the left and right development images of the teeth.

These registration processes are performed in the same manner as described above.
This is performed by processing according to the flowcharts 6 to 20.
The dentist or the like additionally records the patient's symptoms “swelling (+), tenderness (+)” and its position and the incision line that is the treatment content in the registered and displayed picture. Also in this case, since the picture of the tooth itself is automatically read and recorded, it is sufficient to simply enter only the symptoms of the patient and the treatment line. Therefore, it is possible to record the contents of the treatment on the medical record in a short time and correctly.

The recording of the medication is performed in the same manner as in the case 1 described above. The treatment on April 25 in FIG. 25 is almost the same as described above. In the record of the oral surgery procedure on April 25, if "cystectomy (coronary size)" in the oral surgery screen file is selected,
A specific surgical technique of “buccal alveolar bone removal after mucoperiosteal detachment” is also registered.

As described above, in the oral surgery, a specific surgical procedure is determined. In this example, in the case of “cystectomy (crown size)”, the operative procedure is the operative procedure recorded in FIG. Therefore, the operative procedure is also automatically registered by specifying the treatment content. This eliminates the need for a dentist or the like to fill in a medical record each time a word representing a standard surgical procedure is used, and the time required to create a medical record can be reduced.

If the specific technique is different from the displayed technique, it may be corrected each time. Next, the case of Case 3 will be described. Case 3 is a mounting procedure of a complete denture.
In the case of this treatment, after the “first consultation” and the score “170” are registered in the visit registration, site registration is performed. In this case, the part registration shown in FIG. Then, the procedure proceeds to treatment selection, and the prosthetic screen file is read and displayed. The prosthetic screen file has, for example, the contents shown in FIG. The treatment performed on the patient is selected from the treatments described on this screen and registered as the chart data.

The feature of this example is that a picture of a complete denture is recorded in the medical treatment on April 16. The recording of the picture of the complete denture is specifically performed as follows. Referring to FIG. 18, it is determined in step S46 whether or not the registered content is a prosthetic treatment. In the case of a prosthetic treatment, an inquiry as to whether or not a picture of a denture is necessary is displayed on display 9. A dentist or the like inputs whether or not a picture is necessary in response to the inquiry. If there is an input indicating that a picture is required (YES in step S47), the part registration data is read out (step S48), and based on the contents of the prosthetic treatment registration and the part registration, the corresponding denture is extracted from the denture picture file. A picture is selected (step S49). Then, the contents are displayed on the display 9 (step S50).

That is, the dentist etc.
26, the recorded contents of April 16 in FIG. 26 are confirmed. Then, the part and the contents adjusted for the displayed denture picture are written. This content writing can be performed by the handwriting input function of the keyboard 8 or the like, similarly to the content writing in the above-mentioned oral surgery. In the specific example of FIG. 26, the occlusal adjustment is performed on the front two places of the denture, and
It is recorded that the parts were cut off.

As described above, when a denture is worn, a denture picture is entered in the chart and the details of the adjustment are recorded, so that when the patient returns to the hospital, the patient's record is correctly grasped and the next Adjustments can be made appropriately. FIG. 27 shows an example of entry of a medical record of case 4. Case 4 is a mounting procedure of a free denture. Also in this case, the picture of the free end denture is automatically recorded on the chart, and the adjustment part can be added on the picture. The record on April 18 shows an example of the record.

The other details are the same as in the case 3 described above, and thus the detailed description is omitted. By the way, as shown in the “site disease name screen” in FIG. 22, the dental chart is provided with a field for recording a disease name in addition to the region to be treated. According to the system of this embodiment, the recording of this disease name is also performed automatically. Next, the disease name determination and recording processing will be described with reference to the flowchart in FIG.

The disease name determination process shown in FIG. 20 is preferably executed by the CPU according to a program at an appropriate idle time or periodically without waiting for an instruction input by an operator, for example. Of course, for example, each time the treatment selection processing (FIGS. 17 to 19) is completed, the disease name determination processing may be executed automatically or in accordance with an instruction from the operator.

In the disease name determination processing, first, the data of the medical record for which the disease name is determined is read from the medical record file 14 (step S61), and the treatment versus disease name table of the hard disk 13 is searched using the registered treatment contents as an index. (Step S62). If there is a disease name candidate corresponding to the treatment, the disease name candidate is temporarily registered in the disease name field of the medical chart (step S64). In this case, when there are a plurality of disease name candidates, all of the extracted disease name candidates are temporarily registered in the disease name column of the medical chart. In addition,
If there is no disease name candidate in step S63, no disease name is registered in the disease name column, and the process waits for the next disease name determination process.

As a feature of dental care, as described above, the disease name and the treatment content are closely linked.
Therefore, if a certain treatment content is known, it is easy to guess the disease name based on the treatment content. Further, the disease name estimated based on the treatment content is often a correct disease name in most cases. Therefore, in this embodiment, a treatment versus disease name table is provided in the correspondence table of the hard disk, and the disease name for the treatment is registered in advance.

Therefore, as the description of the treatment in the treatment column of the medical chart progresses, the disease name corresponding to the treatment is gradually narrowed down. For example, taking the case 2 described above as an example, from the procedure of “incision (periosteum)”,
Disease name candidates "AA, subperiosteal abscess, palate abscess" are obtained (see FIG. 13). Here, "AA" is an abbreviation for alveolar abscess. Therefore, in case 2, when the treatment on April 22 ends, the above three disease name candidates are registered as disease names.

However, when the treatment progresses and a procedure called “cystectomy (crown size)” is registered on April 25, the disease name candidates are narrowed down to “AA, WZ”. Here, “WZ” is an abbreviation for root cyst. If the disease name is finally one
If it is "AA, WZ" as shown in this example, the dentist may specify any disease name.

As described above, the entry of the disease name in the dental chart is almost automatically performed. According to the system of this embodiment, when insurance medical treatment is performed, a medical remuneration statement to be charged to a predetermined insurance institution can be automatically created. Next, the process for creating the insurance medical fee statement will be described with reference to the flow chart of FIG.

This processing can be performed, for example, by the operator of the reception CPU 1 during the visit registration or at another time. In this process, first, the operation mode of the reception CPU 1 is switched to the mode for the medical fee statement creation process, and the number of the chart for which the statement is to be created is input from the keyboard 3. When the chart number is input (step S71), the CPU 1 searches the chart file 14 (step S72), and reads the data of the input chart (step S73). The part and disease name data in the read medical record data are stored in the work memory 7.
(Step S7)
4). The score data recorded in association with the treatment registration in the medical record data is stored in the work register 2 of the work memory 7 (step S75). Then, the points stored in the work register 2 are totaled, and the cost according to the total points is automatically calculated (step S7).
6). Cost calculation consists of a predetermined processing program,
This is performed based on a cost calculation table stored in association with the program.

Then, the result is displayed on the display 4. The operator who has confirmed the display contents determines whether or not to print, and inputs that fact from the keyboard 3 when printing. When a signal to be printed is given (step S77), the CPU 1 drives the printer 5 to print data on a reward statement set in the printer 5 (step S78).

With the above processing, the insurance medical fee statement can be automatically created. The above embodiment has been described with reference to a chart creation support system in a dental clinic as an example. However, the apparatus of the present invention can be applied not only to dental clinics but also to medical chart creation support in other medical fields.
For example, in a surgical chart creation support system,
If a picture of a bone or the like representing a fracture point to be recorded in the surgical chart is registered in the data file of the hard disk in advance,
By reading the picture, it is possible to automatically fill the chart with the picture of the treatment site.

[Brief description of the drawings]

FIG. 1 is a block diagram showing an outline of a hardware configuration of a system according to an embodiment of the present invention.

FIG. 2 is an expanded view of a data file provided in the system according to one embodiment of the present invention.

FIG. 3 is a diagram showing an example of the contents of a menu screen file in a data file.

FIG. 4 is a diagram showing an example of the contents of a process selection file in a data file.

FIG. 5 is a diagram showing an example of the contents of an X-ray screen file in a data file.

FIG. 6 is a diagram showing an example of the contents of an anesthesia screen file in a data file.

FIG. 7 is a diagram showing an example of the contents of an oral surgery screen file in a data file.

FIG. 8 is a diagram showing an example of the contents of a prosthetic screen file in a data file.

FIG. 9 is a diagram showing an example of the contents of a medication screen file in a data file.

FIG. 10 is a diagram showing an example of the contents of a vertically expanded picture file of a tooth in a data file and a method of extracting a partial picture of a tooth in relation to the file.

FIG. 11 is a diagram illustrating an example of contents of a left-right developed image file of a tooth and a specific example of a method of extracting a partial image of a tooth.

FIG. 12 is a diagram showing an example of the contents of a denture picture file.

FIG. 13 is a diagram showing an example of the contents of a treatment versus disease name table.

FIG. 14 is a diagram showing an example of the contents of a medical treatment score table.

FIG. 15 is a flowchart of a visit registration process.

FIG. 16 is a flowchart of a part registration process.

FIG. 17 is a flowchart (part 1) of a treatment selection process.

FIG. 18 is a flowchart (part 2) of a treatment selection process.

FIG. 19 is a flowchart (part 3) of a treatment selection process.

FIG. 20 is a flowchart of a disease name automatic determination process.

FIG. 21 is a flowchart of insurance medical fee statement preparation processing.

FIG. 22 is a diagram showing an example of a part disease name screen.

FIG. 23 is a diagram showing an example of entry of a part on a part disease name screen.

FIG. 24 is a diagram showing contents recorded in a medical chart in case 1.

FIG. 25 is a diagram showing contents recorded in a medical chart in case 2;

FIG. 26 is a diagram showing contents recorded in a medical chart in case 3;

FIG. 27 is a diagram showing contents recorded in a medical chart in case 4.

[Explanation of symbols]

 DESCRIPTION OF SYMBOLS 1 Reception CPU 2 Medical office CPU 3,8 Keyboard 4,9 Display 5,10 Printer 7,12 Work register 13 Hard disk 14 Floppy disk drive

Claims (1)

[Claims] 1. A treatment versus disease name storage means storing a plurality of treatments and disease name candidates predicted from each treatment, and a treatment storage means for storing a given treatment when a treatment to be recorded in a medical chart is given. Reading means for searching the treatment vs. disease name storage means based on the treatment stored in the treatment storage means and reading a disease name candidate predicted from the treatment; and a disease name candidate read by the reading means. Having a holding means to hold as a disease name to be recorded in the medical record, the reading means, when a new treatment is additionally stored in the treatment storage means, based on a plurality of treatments including the additionally stored treatment, Searching the treatment versus disease name storage means,
Reading means for reading a disease name candidate satisfying all treatments, wherein the holding means updates the held disease name by the disease name candidate read by the reading means; Support equipment.