JP2005049962A - Order issuing method, order issuing program and order issuing device - Google Patents

Abstract

In a hospital, the contents of an order issued as an instruction for medical practice depend on an event that occurs later, for example, a measurement value or a symptom obtained by an examination, and the instruction contents are displayed when a doctor issues an order. In some cases, it was impossible to confirm. In such a case, it is necessary for the nurse to ask the doctor again on the basis of the medical treatment result or to reissue the order again.
Therefore, the present invention is for a nurse to perform a medical practice without requiring a doctor's work again due to an event that occurs later.
According to the present invention, when a doctor issues and registers a pseudo order in which an occurrence event and a medical action instruction are associated with each other and a nurse inputs the occurrence event later, the contents of the medical action registered as the pseudo order are displayed. It is issued and displayed as a formal order.
[Selection] Figure 1

Description

[0001]
BACKGROUND OF THE INVENTION
The present invention relates to a method, a program, and an apparatus for issuing an order that is an instruction of medical practice for a patient performed by a doctor to a nurse or the like in a hospital.
[0002]
[Prior art]
2. Description of the Related Art In recent years, information processing systems in medical institutions have become more sophisticated, and one of them is an electronic medical record system that records and manages medical records that have been stored and managed by paper media in the form of electronic information. Has been introduced. Conventionally, medical treatment requests such as prescription of drugs by doctors and inspections to inspection departments are made orally, or the contents are entered in the electronic medical record of the electronic medical record system, and the nurse gives instructions by the oral In response, or referring to the electronic medical record, the instructions were implemented. Therefore, an ordering system for electronically issuing such various instructions and requests has been introduced in addition to the electronic medical record system.
[0003]
For example, Patent Document 1 includes an input unit having examination results, findings, prescription orders, a storage unit that stores various input data, and a display unit that displays the stored various data as chart information. An electronic medical record system is described.
[0004]
[Patent Document 1]
Japanese Patent Laid-Open No. 5-20338
[Problems to be solved by the invention]
Even in the environment where the electronic medical record system and the ordering system are introduced, the content of the prescription depends on the event that occurs later, for example, the measurement value or symptom obtained by the examination, etc., and when the doctor issues the order In some cases, it was impossible to finalize the instructions. In such a case, it is necessary for the nurse to ask the doctor again based on the test result or the like, or for the doctor to reissue the order.
Therefore, the present invention is for a nurse to perform a prescription treatment or the like without requiring a doctor's work again due to an event that occurred later in order to solve the above-described problem.
[0006]
[Means for Solving the Problems]
The present invention issues and registers a pseudo-order in which a doctor associates the occurrence event with the contents of the medical action instruction to be given to the patient, such as prescription, and registers as a pseudo-order when the nurse inputs the occurrence event later The contents of the prescribed prescription are issued and displayed as a formal order. This occurrence event refers to a record of all medical practices including various test results, observation results, patient symptoms, and the like for the patient. The record of the medical practice is input and stored in the electronic medical chart system as medical chart data.
[0007]
Specifically, the order issuing method according to the present invention includes an input receiving step for receiving, as medical record data, information related to recording of a medical practice for a patient, an order that is an instruction of a medical practice to be performed for a patient, and the order A determination step for determining whether or not the contents of the medical record data match the corresponding event with reference to the pseudo-order DB stored in association with the corresponding event that is a condition for issuing an order, and the determination step When it is determined that the order matches, the order issuing step for displaying the order associated with the corresponding event is provided.
[0008]
By providing the above steps, the nurse can input an event that has occurred later regarding the patient, and can perform appropriate medical practice on the patient without asking the doctor again.
[0009]
DETAILED DESCRIPTION OF THE INVENTION
Embodiments of the present invention will be described with reference to the drawings. As shown in FIG. 1, the present embodiment constitutes a form in which an electronic medical record server 10, a medical accounting server 11, and a plurality of client terminals 12 are connected via a network 13.
[0010]
The server 10 includes an electronic medical record system 14 and an ordering system 15, and includes a medical record information DB 16, a pseudo order DB 17, and a pseudo order support master 18 that are referred to by these systems.
[0011]
The electronic medical record system 14 is a system in which a doctor inputs medical treatment contents and manages them as medical record data.
[0012]
The ordering system 15 issues an order which is a medical treatment request such as prescription of a medicine by a doctor and an inspection to an inspection department, and includes a pseudo-order input registration program 151 and an official order issue program 152 according to the present invention. .
[0013]
The pseudo-order input registration program 151 is a program that describes a process for a doctor to input and register a medical action instruction such as prescription to be performed on the condition that a certain event has occurred later as a pseudo-order.
[0014]
The formal order issuance program 152 is a program that describes a process for issuing an order when a nurse or the like inputs a test result of a patient and the condition conforms to an event preset as an order issuance condition. is there.
[0015]
Detailed processing contents of these programs will be described later.
[0016]
The medical record information DB 16 is a database that stores attributes of each patient and medical contents such as examination results. Its details are shown in FIG. The patient information 20 stores the name of the patient and the attributes of the patient, and the attributes include age, sex, height, weight, and disease name. The pseudo-order target 21 indicates whether or not a pseudo-order has been issued for the patient, and is set as “target” if issued, and “non-target” if not issued. The inspection date 22 is set to a date on which various inspections are actually performed and data relating to the inspection result is input. As the inspection result 23, the results of various inspections are inputted and stored. In the present embodiment, “GOT”, “GPT”, and “red blood cell count”, which are blood test results, and “body temperature” and “blood pressure” test results classified into general tests are input and stored. .
[0017]
The pseudo order DB 17 is a database that stores the contents of issued pseudo orders, and the contents are shown in FIG. The instruction date 30 stores the date on which the pseudo order is issued. The issuer 31 stores the name of the person who issued the pseudo-order, and the doctor name is stored in this embodiment. The patient information 32 stores information on the name and attributes of the patient who is the target of the pseudo order. In the present embodiment, sex, age, height, weight, and disease name are stored as attributes. These pieces of information are extracted from the patient information 20 in the medical record information DB 16 when the pseudo-order is input and created. The valid period 33 is a period in which the pseudo order is applied, set and stored based on the start and end dates. The corresponding event 34 is an event that is a condition for order issue and is set and stored with items and numerical values. For example, a pseudo-order issued to a patient whose name is “Taro Kawasaki” is issued as a formal order when the “body temperature” exceeds “40” degrees as a test result of the patient. It is. The order content 35 is set and stored with the content of a formal order that is actually issued when an event that is a condition for order issuance occurs. For example, a pseudo-order issued to a patient whose name is “Taro Kawasaki” indicates that the medication name “AAA” is given once when the “body temperature” exceeds “40” degrees as the test result of the patient. It is issued as an order to prescribe a total of “6” times as a quantity “3” tablets.
[0018]
The pseudo-order support master 18 is a database that stores the amount to be taken at one time for each prescription medication name, and details are shown in FIG. The medication name 40 stores the name of the medication to be prescribed. The single dose 41 is a memorized standard dose for each patient age and weight. The pseudo order support master 18 is used in two ways. One of them is used as a reference for a one-time amount to be input to the order contents 35 when a doctor creates and issues a pseudo-order. The other is not to set a specific numerical value for the one-time amount of the order contents 35, but to simply set “standard”, in order to obtain a specific numerical value when issuing a formal order, Reference may be made during the processing of the program 152.
[0019]
The medical accounting server 11 includes a medical accounting system 19 that receives and manages information related to accounting when an order such as a prescription is issued by the ordering system.
[0020]
In this embodiment, as shown in FIG. 1, an electronic medical record server 10 and a medical accounting server 11 are provided as hardware server computers, and an electronic medical record system 14 and an ordering system 15 are configured in the electronic medical record server 10. Although the medical accounting server 11 is configured to configure a medical accounting system, the embodiment of the present invention is not limited to such a configuration. For example, a separate server computer may be provided for each system and connected via a network, or all systems may be configured as a single server computer. The difference does not affect the essence of the present invention.
[0021]
The client terminal 12 is operated by a doctor, a nurse, or the like, and is connected to each server via the network 13. This is for sending the contents of the pseudo-order entered by the doctor and information on various test results entered by the nurse to each server, and for receiving and displaying the contents of the order sent by the server. .
[0022]
Next, operation examples of the present invention will be described with reference to the flowcharts shown in FIGS.
[0023]
In the processing of the present invention, the contents of the pseudo order are created and input by a doctor or the like, and the result is registered in the pseudo order DB 17 and the results of various examination results of the patient input by the nurse are the results of the order issuance. When the condition is met, it can be broadly divided into processing for converting the contents of the prescription registered as a pseudo-order into a formal order and issuing it.
[0024]
FIG. 5 is a flowchart for explaining a process in which the pseudo order input registration program 151 accepts a pseudo order input created by a doctor or the like and registers it in the pseudo order DB 17.
[0025]
In step S51, an input of the name of a patient to be issued as a pseudo-order to be issued by a doctor or the like is accepted. The data related to the patient name is input from the client terminal 12 by a doctor or the like.
[0026]
In step S52, based on the information regarding the patient's name received in step S51, the patient information 20 of the patient is read with reference to the medical record information DB 16, and registered as the patient information 32 in the pseudo-order DB 17. For example, when “Taro Kawasaki” is accepted as the patient's name in step S51, “Taro Kawasaki” is searched from the “Name” item of the patient information 20 in the medical record information DB 16, and “Age” is “30”. , “Gender” is “male”, “height” is “165” cm, “weight” is “55” Kg, and “disease name” is “migraine”. Then, the read information is registered as patient information 32 of the pseudo order DB 17.
[0027]
In step S53, the validity period of the pseudo order and the input of an event that is a condition to be issued as a formal order are received and registered in the valid period 33 and the corresponding event 34 of the pseudo order DB 17, respectively. In the pseudo-order issued to the patient with the name “Taro Kawasaki”, the validity period 33 is set from February 1, 2003 to February 14, 2003, and the corresponding event 34 is “item”. As the conditions of “body temperature” and “numerical value”, the order is set to be issued when “40” degrees are exceeded.
[0028]
The processes in steps S54 to S55 are for assisting a doctor or the like in inputting the order contents 35. If a doctor or the like has detailed knowledge about the medicine to be prescribed, the “number of times” of “one dose” which is the amount to be taken at once as the order content 35 without referring to anything in particular Etc. can be input. However, if the doctor or the like does not have detailed knowledge, the pseudo-order support master 18 may be referred to obtain information related to the “single dose” suitable for the patient and input as the order content 35. In step S54, a message asking whether or not to refer to the pseudo-order support master 18 is transmitted to the client terminal 12 operated by the doctor or the like, and the doctor or the like performs an operation for displaying an intention to refer to the message. If the information is returned from the client terminal 12, the process proceeds to step S55. If a doctor or the like performs an operation for displaying an intention that the reference is unnecessary, and if the information is returned from the client terminal 12, the process proceeds to step S56.
[0029]
In step S55, the contents of the pseudo order support master 18 are transmitted to the client terminal 12. The client terminal 12 displays the contents of the pseudo order support master 18 to be referred to by a doctor or the like.
[0030]
In step S56, the “medicine name”, “single dose”, and “number of times” input by the doctor or the like via the client terminal 12 are received and registered as the order content 35. The patient with the name “Taro Kawasaki” is registered as “AAA” as “medicine name”, “3” tablets as “dose”, and “6” as “number of times”. Here, it is possible to input a specific quantity as an item of “one dose”, and input “standard” which is predetermined character string data as in the example of the patient with the name “Harumi Ueno”. It is also possible to do. The subsequent processing when “standard” is entered will be described later.
[0031]
Since the purpose of the pseudo order input registration program 151 is to finally complete the pseudo order data in the pseudo order DB 17, the processes in steps S51 to S52, the processes in step S53, and the steps S54 to step are performed. The order of each process of S56 can be interchanged. In this implementation expectation, the processing sequence shown in FIG. 5 is taken as an example.
[0032]
In step S57, the input is accepted up to step S56, and the registration is confirmed for the contents of the pseudo order registered in the pseudo order DB 17. Here, the instruction date 30 which is the date when the pseudo order is registered and the issuer 31 such as a doctor who issued the pseudo order are also registered. For the patient with the name “Taro Kawasaki”, “January 31, 2003” is registered as the instruction date 30, and “Natsumi Nakahara” is registered as the issuer 31. Furthermore, the item of the pseudo-order target 21 of the patient in the medical record information DB 16 is set as “target”. This indicates that a pseudo-order has been issued for the patient. For the patient with the name “Taro Kawasaki”, the pseudo-order has been issued in the process so far, The item is set to “Target”.
[0033]
FIG. 7 shows an example of an input screen displayed on the client terminal 12 during the processing of the pseudo order input registration program 151 described above.
[0034]
FIG. 6 is a diagram for explaining a process in which the formal order issuing program 152 receives a test result input by a nurse or the like and issues a formal order when the contents correspond to an event that is a condition for issuing the order. It is a flowchart.
[0035]
In step S61, the nurse or the like receives information related to the patient test result input and transmitted via the client terminal 12. This inspection result is registered in the inspection result 23 of the medical record information DB 16. For example, for a patient with the name “Taro Kawasaki”, “GOT” is “25”, “GPT” is “24”, and “red blood cell count” is “450” as a result of the test conducted on February 1, 2003. “Body temperature” is registered as “38.5”, and “Blood pressure” is registered as “110”. This test result 23 is additionally input and registered when the same patient is tested. The patient with the name “Taro Kawasaki” was also examined on February 4, 2003, and the examination result 23 was entered. FIG. 8 shows an example of an inspection result input screen displayed on the client terminal 12.
[0036]
In step S62, it is determined whether or not a pseudo order has been issued for the patient to whom the test result 23 is input. If it has been issued, the process proceeds to step S63, and if not, the process ends. That is, when the test result 23 is input and registered, the item of the pseudo-order target 21 for the patient is referred to, and if “target” is set, it is determined that the pseudo-order is issued, and “non-target” Is set, it is determined that a pseudo order has not been issued. For the patient with the name “Taro Kawasaki”, since the pseudo-order target 21 is set as “target”, it is determined that the pseudo-order has been issued.
[0037]
In step S63, it is determined whether or not the input inspection result 23 is compatible with the corresponding event 34 that is the condition for issuing the order. If it matches, the process proceeds to step S64, and if not, the process ends. For the patient with the name “Taro Kawasaki”, as the applicable event 34, an order is set to be issued when “body temperature” exceeds “40” degrees. Accordingly, in the test result 23 on February 1, 2003, the “body temperature” is “38.5” degrees and does not conform to the corresponding event 34, so the processing ends, but on February 4, 2003 In the test result 23, the “body temperature” is “40.5” degrees, and since it matches the event 34, the process proceeds to step S64.
[0038]
In step S64, it is determined whether or not “standard” is set by referring to “single amount” of the order content 35 of the pseudo-order. If it is set, the process proceeds to step S65 and must be set. If so, the process proceeds to step S66. “Standard” is set because doctors do not specify a single dose, but specify the appropriate dose for the patient in the medicine. The quantity is set in the pseudo order support master 18. For the patient with the name “Taro Kawasaki”, the “single dose” in the order contents 35 is set to “3” tablets with a specific value, but for the patient with the name “Ueno Harumi” “standard” Is set.
[0039]
In step S65, referring to the pseudo-order support master 18, based on the “medicine name” of the patient information 32 and the order content 35, a process of extracting the “single dose” of the medicine suitable for the patient is performed. Taking a patient with the name “Harumi Ueno” as an example, the “medicine name” prescribed as an order is “BBB”, the “age” in the patient information 32 is “27”, and the “weight” is “47”. “Kg”, the dosage name 40 of the pseudo-order support master 18 refers to a single dose 41 of “BBB”, “age” is “21 to 60 years old”, and “weight” is “˜50 kg”. From this, the appropriate “dose” is obtained as “6” tablets.
[0040]
In step S 66, the order contents 35 obtained up to step S 65 are issued as a formal order and transmitted to the client terminal 12. For patients with the name “Taro Kawasaki”, the prescription that “medicine name” set in order contents 35 is “AAA”, “single dose” is “3” tablets, and “number of times” is “6” times. Is issued as a formal order. FIG. 9 shows an example of an order display screen transmitted to the client terminal 12.
[0041]
In step S67, the accounting information associated with the issued order is transmitted to the medical accounting system 19. The accounting information includes the price of the pharmaceutical issued as an order.
[0042]
In the present embodiment, as an example of an order, a case of pharmaceutical prescription has been described, but the content of the order is not limited to this. For example, a text sentence may be used as the issued order. In other words, when it is desired to issue an order such as contacting a specialist when a certain event occurs, a sentence to that effect may be set in the order content 35.
[0043]
Although not shown, the electronic medical record server 10, the medical accounting server 11, and the client terminal 12 are computers whose entire apparatus is controlled by a CPU (Central Processing Unit). A RAM (Random Access Memory), a hard disk device (HDD), a graphic processing unit, an input interface, a communication interface, and the like are connected to the CPU via a bus.
[0044]
The RAM temporarily stores at least a part of an OS (Operating System) program to be executed by the CPU and other programs. The RAM stores various data necessary for processing by the CPU. The HDD stores an OS and other programs and data.
[0045]
A monitor device is connected to the graphic processing unit. The graphic processing unit displays an input screen or the like on the monitor device in accordance with a command from the CPU. A keyboard and a mouse are connected to the input interface. The input interface transmits a signal sent from a keyboard, a mouse, or the like to the CPU via the bus.
[0046]
The communication interface is connected to the network 13. The communication interface transmits / receives data to / from the electronic medical record server 10, the medical accounting server 11, and the client terminal 12 via the network 13.
[0047]
By causing the above-described computer to execute the pseudo-order input registration program 151 and the formal order issuance program according to the embodiment of the present invention, the computer can function as an order issuance apparatus.
[0048]
The processing contents of the functions that the computer should have can be described in a program recorded on a computer-readable recording medium. By executing this program on a computer, the above processing can be realized on the computer. Examples of the computer-readable recording medium include a magnetic recording device and a semiconductor memory. When distributing to the market, the program is stored in a portable recording medium such as a CD-ROM (Compact Disk Read Only Memory) or a flexible disk, or stored in a computer storage device connected via a network. In addition, it can be transferred to another computer through the network. When executed by a computer, the program is stored in a hard disk device or the like in the computer, loaded into the main memory, and executed.
[0049]
【The invention's effect】
As described above, according to the present invention, the content of the medical practice such as prescription depends on the event that occurs later, for example, the measured value or symptom obtained by the examination, and the content of the instruction at the time when the doctor issues an order. Even if it is impossible to determine the prescription, it is possible for the nurse to perform a prescription or the like in accordance with an event that has occurred later, without requiring the work of a doctor again.
[Brief description of the drawings]
FIG. 1 is a configuration diagram for realizing the present invention.
FIG. 2 illustrates a medical record information DB.
FIG. 3 illustrates a pseudo order DB.
FIG. 4 illustrates a pseudo order support master.
FIG. 5 is a flowchart illustrating processing of a pseudo order input registration program.
FIG. 6 is a flowchart illustrating processing of a formal order issue program.
FIG. 7 illustrates an example of a pseudo order input screen.
FIG. 8 illustrates an example of an inspection result input screen.
FIG. 9 shows an example of a formal order issue screen.
[Explanation of symbols]
10 Electronic Medical Record Server 11 Medical Accounting Server 12 Client Terminal 13 Network 14 Electronic Medical Record System 15 Ordering System 151 Pseudo Order Input Registration Program 152 Formal Order Issuance Program 16 Medical Record Information DB
17 Pseudo order DB
18 Pseudo-order support master 19 Medical accounting system 20 Patient information 21 Pseudo-order target 22 Examination date 23 Examination result 30 Instruction date 31 Issuer (doctor name)
32 Patient information 33 Valid period 34 Corresponding event 35 Order contents 40 Medication name 41 Single dose

Claims (5)

In a method in which a computer issues an order that is an instruction of medical practice to be performed on a patient,
An input receiving step for receiving, as medical chart data, information related to a record of medical treatment for the patient;
A determination step for determining whether or not the contents of the medical record data match the corresponding event with reference to the pseudo-order DB that stores the order and the corresponding event that is a condition for issuing the order in association with each other; ,
An order issuing method, comprising: an order issuing step of transmitting the order associated with the corresponding event when it is determined that it is compatible in the determining step. The order includes a medication name to be prescribed to the patient and a single dose that is the amount of medication to be taken at one time,
When predetermined data is set as the single dose, or when data is not set, pseudo-order support for storing the medication name and attribute information related to the patient and the single dose in association with each other 2. The order issuing method according to claim 1, further comprising the step of taking out the one-time dose based on a medication name included in the order and attribute information about the patient with reference to a master. A program for operating a computer, and an input receiving means for receiving, as medical chart data, input of information related to a record of medical treatment for a patient to the computer;
A pseudo-order DB that stores an order that is an instruction of a medical practice to be performed on a patient and a corresponding event that is a condition for issuing the order in association with each other;
A determination unit that refers to the pseudo-order DB and determines whether or not the contents of the medical record data match the corresponding event;
An order issuing program for functioning an order issuing means for transmitting the order associated with the corresponding event when it is determined that the determination means matches. The order includes a medication name to be prescribed to the patient and a single dose that is the amount of medication to be taken at one time,
A pseudo-order support master that stores the medication name and attribute information related to the patient and the single dose in association with each other;
When predetermined data is set as the one-time dose, or when data is not set, the pseudo-order support master is referred to, and a medication name included in the order and attribute information about the patient are used. 4. The order issuing program according to claim 3, further comprising means for taking out the one-time amount based on the order. In a device that issues an order that is an instruction of medical practice to be performed on a patient,
Input accepting means for accepting input of information relating to a record of medical practice for the patient as medical record data;
A pseudo order DB that stores the order and a corresponding event that is a condition for issuing the order in association with each other;
A determination unit that refers to the pseudo-order DB and determines whether or not the contents of the medical record data match the corresponding event;
An order issuing device, comprising: an order issuing unit that transmits the order associated with the corresponding event when the determination unit determines that the data matches.

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