Medical record creation support device, medical record creation support method, and medical record creation support program

Abstract

The present invention provides a medical record creation support device that can present appropriate medical record entries for each patient to doctors and other medical professionals. [Solution] The system includes an acquisition unit 10 that acquires patient information for each patient and medical information corresponding to the medical treatment provided to the patient; an interface 4 that outputs status information and medical information to an AI server 20 that generates example information equivalent to an example of how to write in the patient's medical record corresponding to the status information and medical information, and acquires the generated example information from the AI ​​server 20; and a display 5 that presents the acquired example information to doctors and others who claim medical fees for each patient.

Description

Technical Field

[0001] The present invention belongs to the technical field of a medical record creation support device, a medical record creation support method, and a program for medical record creation support. More specifically, it belongs to the technical field of a medical record creation support device and a medical record creation support method for supporting the creation of medical records created by doctors or in-charge clerks (office staff), etc., and a program for the medical record creation support device.

Background Art

[0002] Currently, in the Japanese medical system, in order to conduct insurance medical treatment, it is essential to record the necessary items in the medical record (so-called medical chart). As such necessary items, it is required to record without omission the items that serve as the basis for calculating insurance medical treatment fees, especially various medical management fees, etc. And, as a prior art document showing the prior art for coping with such requirements in insurance medical treatment, for example, the following Patent Document 1 can be cited. In the prior art disclosed in this Patent Document 1, diagnostic assistance using interrogation by artificial intelligence (AI) is performed, and thereby the labor of doctors in creating medical charts is reduced.

Prior Art Documents

Patent Documents

[0003]

Patent Document 1

Summary of the Invention

Problems to be Solved by the Invention

[0004] However, in actual clinical practice, due to the busy schedules of the doctors in charge, even when utilizing the assistance provided by the prior art described in Patent Document 1, for example, the medical records, for which the doctor is ultimately responsible, may only contain the essential points. As a result, the records may not be tailored to the individual circumstances of each patient the doctor treats, or they may be insufficiently documented. In some cases, the medical records themselves may be insufficient. Therefore, to improve this situation, there is a need for electronic tools to support busy doctors and their administrative staff.

[0005] Therefore, the present invention has been made in view of the above requirements, and one example of the problems it addresses is to provide data for each patient and in chronological order (i.e., non-uniformly). )suitable The objective is to provide a medical record creation support device and method, as well as a program for the medical record creation support device, that can present important medical record entries to doctors and other medical professionals. [Means for solving the problem]

[0006] To solve the above problems, the invention described in claim 1 is: insurance The patient receiving medical treatment insurance This includes information that describes the patient's physical condition at the time of treatment and identification information to distinguish the patient from other patients. Medical interview Information 、 The insurance Entered by a physician or administrative staff member involved in the medical treatment. Furthermore, a medical interview corresponding to the content of the medical interview with the aforementioned patient. Information acquisition means such as an acquisition unit that acquires information for each patient, and the patient insurance Medical fee information that corresponds to medical treatment and was entered by the aforementioned physician or administrative staff. to A means for acquiring medical fee information, such as an acquisition unit, for each patient, A means for acquiring medical fee information, such as an acquisition unit, which acquires medical fee statement information corresponding to the contents of the medical fee statement created in accordance with the medical fees for the aforementioned insured medical treatment for each patient, Each of the acquired Medical interview information Medical fee information and medical fee information An output means that outputs to a learning device, wherein the learning device , (i) At least the calculation method of the medical fees in the aforementioned insured medical treatment and / or the application method of said medical fees have been trained using training data for said calculation method and / or application method, and (ii) consistency confirmation information indicating whether or not the contents of each of the acquired medical interview information, medical fee information and medical fee statement information are consistent with each other is generated and output based on the training results of the training data, and (iii) the medical interview information, medical fee information and medical fee statement information correspond to the aforementioned insured medical treatment and When medical treatment was performed The relevant insured medical treatment and For the aforementioned patient, the appropriate medical record entry information corresponds to the example entry. Based on the aforementioned learning results A learning device that generates and outputs data. dea Output means such as an interface, and each of the output Medical interview information Medical fee information and generated / output by the learning device based on medical fee information The aforementioned consistency confirmation information and The above example information From the learning device Means for acquiring information such as the interface to be acquired, Based on the consistency verification information obtained, The acquired example information is insurance Claiming medical fees for medical treatment Doctor The system includes a reflection / display control unit and a display or other presentation means that are presented to each patient, and using the presented example information, insurance The contents of the medical record of the patient who received treatment were finalized by the aforementioned physician. ru.

[0007] To solve the above problems, Claim 7 The invention described above comprises a means for acquiring patient information such as an acquisition unit, and a means for acquiring medical information such as an acquisition unit, means for acquiring specification information such as the acquisition unit, A medical record creation support method performed in a medical record creation support device comprising output means such as an interface, information acquisition means such as an interface, a reflection / display control unit and presentation means such as a display, insurance The patient receiving medical treatment insurance This includes information that describes the patient's physical condition at the time of treatment and identification information to distinguish the patient from other patients. Medical interview Information 、 The insurance Entered by a physician or administrative staff member involved in the medical treatment. Furthermore, a medical interview corresponding to the content of the medical interview with the aforementioned patient. A patient information acquisition step in which information is acquired for each patient using the patient information acquisition means, and a step performed on the patient insurance Medical fee information that corresponds to medical treatment and was entered by the aforementioned physician or administrative staff. to A process for obtaining medical fee information obtained for each patient using the medical information acquisition means, A procedure for acquiring medical fee statement information for each patient using the medical fee statement information acquisition means, which includes: Each of the acquired Medical interview information Medical fee information and medical fee information An output step in which the output means outputs to a learning device, wherein the learning device , (i) At least the calculation method of the medical fees in the aforementioned insured medical treatment and / or the application method of said medical fees have been trained using training data for said calculation method and / or application method, and (ii) consistency confirmation information indicating whether or not the contents of each of the acquired medical interview information, medical fee information and medical fee statement information are consistent with each other is generated and output based on the training results of the training data, and (iii) the medical interview information, medical fee information and medical fee statement information correspond to the aforementioned insured medical treatment and When medical treatment was performed The relevant insured medical treatment and For the aforementioned patient, the appropriate medical record entry information corresponds to the example entry. Based on the aforementioned learning results A learning device that generates and outputs dea an output process, and for each of the output Medical interview information Medical fee information and based on the medical fee information, the description example information generated / output in the learning device The aforementioned consistency confirmation information and the above-described example information by the information acquisition means From the learning device an information acquisition process for acquiring, Based on the consistency verification information obtained, the acquired description example information, the insurance medical fee for medical treatment to claim Doctor a presentation process of presenting to the patient for each patient by the presentation means, and using the presented description example information, the insurance contents of the medical record of the patient who has received medical treatment are determined by the doctor.

[0008] To solve the above problems, the invention according to claim 8 is a computer included in a medical record creation support device, insurance for each patient who has received medical treatment, the insurance information including identification information for identifying the patient from other patients and indicating the physical state of the patient during the medical treatment Medical interview information that is 、 the insurance information input by a doctor or a clerk involved in the medical treatment, a patient information acquisition means for acquiring for each patient, the Furthermore, a medical interview corresponding to the content of the medical interview with the aforementioned patient. medical fee information corresponding to the medical treatment performed on the patient and input by the doctor or the clerk insurance a medical fee information acquisition means for acquiring for each patient, to for each of the acquired A statement information acquisition means for acquiring statement information for each patient that corresponds to the contents of the statement of medical fees prepared in accordance with the medical fees for the aforementioned insured medical treatment. information Medical interview and medical fee information Medical fee information and, An output means that outputs to a learning device, wherein the learning device (i) At least the calculation method of the medical fees in the aforementioned insured medical treatment and / or the application method of said medical fees have been trained using training data for said calculation method and / or application method, and (ii) consistency confirmation information indicating whether or not the contents of each of the acquired medical interview information, medical fee information and medical fee statement information are consistent with each other is generated and output based on the training results of the training data, and (iii) the medical interview information, medical fee information and medical fee statement information correspond to the aforementioned insured medical treatment and at the time when the medical treatment is performed, The relevant insured medical treatment and description example information corresponding to the content of the medical record description example appropriate for the patient Based on the aforementioned learning results a learning device that generates and outputs dea an output means, for each of the output Medical interview information Medical fee information and based on the medical fee information, the description example information generated / output in the learning device The aforementioned consistency confirmation information and ​​​The means of acquiring the information, and Based on the consistency verification information obtained, The acquired example information is insurance Claiming medical fees for medical treatment Doctor A medical record creation support program that functions as a presentation means for presenting information to each patient, using the presented example information, insurance The contents of the medical record of the patient who received treatment are finalized by the aforementioned physician.

[0009] Claim 1, Claim 7 or claim 8 According to the invention described in any one of the paragraphs, Based on the results of the verification of whether the contents of the medical interview information, medical fee information, and medical fee statement information are consistent with each other, the physician is presented with example information that corresponds to the content of the medical record corresponding to the medical interview information, medical fee information, and medical fee statement information. Therefore, the medical record is in a state where the medical interview information, medical fee information, and medical fee statement information are consistent with each other. information , the medical fee information and the medical fee statement This allows physicians to be presented with appropriate and non-uniform examples of medical record entries tailored to each patient's information.

[0020] To solve the above problems, Claim 2 The invention described in the claim 1 In the medical record creation support device described above, if the consistency confirmation information indicates that there is an inconsistency between the contents of the medical interview information, the medical fee information, and the medical fee statement information, the presentation means will present the acquired example information to the Doctor It is configured to be presented to each of the aforementioned patients.

[0021] Claim 2 According to the operation of the invention described in the claim, 1 In addition to the effects of the invention described above, if the consistency confirmation information indicates that there is an inconsistency between the contents of the medical interview information, medical fee information, and medical fee statement information, the example information will be provided. Doctor Since this information is presented to each patient individually, we need more appropriate and non-uniform examples of medical record entries that ensure consistency between the contents of the medical interview information, medical fee information, and medical fee statement information. Doctor It can be presented to them.

[0022] To solve the above problems, Claim 3 The invention described in the claim 1In the medical record creation support device described above, the presentation means scores the degree of consistency based on the consistency confirmation information using a pre-set scoring method. Doctor The system further includes scoring means such as a scoring unit that presents a score to each patient.

[0023] Claim 3 According to the operation of the invention described in the claim, 1 In addition to the effects of the invention described above, the consistency between the contents of the medical interview information, medical fee information, and medical fee statement information is scored for each patient. Doctor It will be presented to you, Doctor This consistency can be objectively recognized.

[0024] To solve the above problems, Claim 4 The invention described in the claim 1 In the medical record creation support device described above, based on the medical interview information and the medical fee information, Doctor The system further includes a medical record information acquisition means, such as an acquisition unit, which acquires medical record information corresponding to the contents of the medical record created for the patient. The output means outputs each of the acquired medical interview information, medical fee information, medical fee statement information, and medical record information to the learning device. The information acquisition means is configured to acquire the generated consistency confirmation information and example information from the learning device in correspondence with the medical interview information, medical fee information, medical fee statement information, and medical record information.

[0025] Claim 4 According to the operation of the invention described in the claim, 1 In addition to the effects of the invention described above, the following description examples are provided that correspond to the medical interview information, medical fee information, medical fee statement information, and medical record information. Doctor Since it will be presented, it will be more appropriate and non-uniform examples of how to write medical records for each patient that correspond to the medical record you have created, including medical interview information, medical fee information and medical fee statement information. Doctor It can be presented to them.

[0026] To solve the above problems, Claim 5The invention described in the claim 4 In the medical record creation support device described above, the presentation means modifies the medical record information using the acquired example information, and the modified medical record information is described above Doctor It is configured to be presented to [the specified location].

[0027] Claim 5 According to the operation of the invention described in the claim, 4 In addition to the effects of the invention described above, the medical record information modified using the acquired example information is also available. Doctor It will be presented to you, Doctor While reducing the effort involved, we aim to create more appropriate and non-standardized examples of medical record entries for each patient. Doctor It can be presented to them.

[0028] To solve the above problems, Claim 6 The invention described is as described in Claims 1 to Claims 5 In the medical record creation support device described in any one of the paragraphs, the present example information is based on the Doctor The system further includes a reception means, such as an operation unit, for receiving the modification operation of the medical record.

[0029] Claim 6 According to the operation of the invention described above, claims 1 to claim 5 In addition to the effects of the invention described in any one of the paragraphs, based on the description example information Doctor This allows for revisions to the contents of the medical record, making the entries in the medical record more appropriate and less uniform. [Effects of the Invention]

[0030] According to the present invention, Based on the results of the verification of whether the contents of the medical interview information, medical fee information, and medical fee statement information are consistent with each other, the physician is presented with example information that corresponds to the content of the medical record corresponding to the medical interview information, medical fee information, and medical fee statement information.

[0031] Therefore, A medical record in which the medical interview information, medical fee information, and medical fee statement information are consistent, and the medical interview information , the medical fee information and the medical fee statement Examples of appropriate and non-uniform medical record entries for each patient, corresponding to the information provided. Doctor It can be presented to them. [Brief explanation of the drawing]

[0032] [Figure 1] This is a block diagram showing the outline configuration of the medical record creation support system according to the first embodiment. [Figure 2] This is a flowchart showing the medical record creation support process of the first embodiment. [Figure 3] This figure shows an example of the screen displaying the results of the medical record creation support process in the first embodiment. [Figure 4] This figure illustrates the contents of a medical claim form obtained as a result of the medical record creation support process in the first embodiment. [Figure 5] This is a block diagram showing the outline configuration of the medical record creation support system of the second embodiment. [Figure 6] This is a flowchart showing the medical record creation support process of the second embodiment. [Modes for carrying out the invention]

[0033] Next, several embodiments of the present invention will be described with reference to the drawings. The embodiments described below are examples in which the present invention is applied to a medical record creation support system, which includes a medical record creation support device that assists a doctor in a clinic in creating medical records for patients under the doctor's care.

[0034] (1) First Embodiment First, a first embodiment of the present invention will be specifically described with reference to Figures 1 to 4. Figure 1 is a block diagram showing the general configuration of the medical record creation support system of the first embodiment, and Figure 2 is a flowchart showing the medical record creation support process of the first embodiment. Furthermore, Figure 3 is a diagram showing an example of the screen showing the result of the medical record creation support process, and Figure 4 is a diagram illustrating the contents of a medical claim form (medical fee statement) obtained as a result of the medical record creation support process. In this case, the patient corresponds to an example of a "patient" of the present invention, and the physician or the administrative staff assisting them corresponds to an example of a "claimant" of the present invention.

[0035] As shown in Figure 1, the medical record creation support system SS of the first embodiment consists of a medical record creation support device S of the first embodiment, an AI server 20 of the first embodiment, and a network NW such as the Internet that connects the medical record creation support device S and the AI ​​server 20 to enable data exchange.

[0036] In this case, the AI ​​server 20 is an AI server that has been trained on the calculation method and / or application method of medical fees in health insurance medical care using a large amount of training data on the calculation method and / or application method of said medical fees. Examples of training data in this case include the content data of explanatory documents on the above calculation method and application method, and data on past examples of the calculation method and application method in many other clinics or hospitals. When the AI ​​server 20 receives patient information etc. from the medical record creation support device S as described in the first embodiment later, it has the function of sending back example information to the medical record creation support device S that is an appropriate example of how to write a medical record corresponding to the patient information etc., and an example that is considered appropriate for the patient at that time (i.e., a non-uniform example of how to write a medical record). In this case, the example information includes billing conditions based on patient information and medical fee information, and content that satisfies the billing conditions required for billing medical fees.

[0037] On the other hand, the medical record creation support device S of the first embodiment is composed of a processing unit 1, a recording unit 2 consisting of an HDD (Hard Disk Drive) or SSD (Solid State Drive), an operation unit 3 consisting of a keyboard and mouse, an interface 4, and a display 5 consisting of a liquid crystal display. Furthermore, the processing unit 1 is composed of an acquisition unit 10, a medical fee calculation unit 11 connected to the interface 4 and the display 5, a medical record entry example acquisition unit 12 connected to the interface 4, a reflection / display control unit 13 connected to the display 5, a medical record content confirmation unit 14, and a recording control unit 15. In this case, the acquisition unit 10, the medical fee calculation unit 11, the medical record entry example acquisition unit 12, the reflection / display control unit 13, the medical record content confirmation unit 14, and the recording control unit 15 may each be realized by hardware logic circuits constituting the processing unit 1, or they may be realized in software by the processing unit 1 reading and executing a program that corresponds to the medical record creation support processing of the first embodiment described later and is pre-recorded in the recording unit 2. Furthermore, the acquisition unit 10 corresponds to an example of the "status information acquisition means," an example of the "medical fee information acquisition means," and an example of the "medical record information acquisition means" of the present invention, respectively. Also, the interface 4 corresponds to an example of the "output means" and an example of the "information acquisition means" of the present invention, respectively, the reflection / display control unit 13 and the display 5 correspond to an example of the "presentation means" of the present invention, and the operation unit 3 corresponds to an example of the "reception means" of the present invention.

[0038] In the above configuration, the acquisition unit 10 of the processing unit 1 acquires patient information, including physical information of patients receiving medical treatment from a doctor at a clinic equipped with a medical record creation support device S, and medical fee information, when the doctor or their office staff inputs the input via the operation unit 3. Examples of patient information input at this time include information on the patient's past medical records, past prescription history and prescription details, past examination history and document issuance history, age information, gender information, current height information, current weight information, smoking history information, alcohol consumption history information, allergy onset history information, or current contraindicated drug information, all of which are associated with identification information used to distinguish the patient from other patients. Subsequently, the medical fee calculation unit 11 of the processing unit 1 calculates the medical fee corresponding to the medical fee information input via the acquisition unit 10 using a predetermined calculation method, and temporarily displays the calculated medical fee on the display 5. In addition, the medical fee calculation unit 11 outputs the patient information and medical fee information input via the acquisition unit 10 to the AI ​​server 20 via the interface 4 and the network NW. As a result, the AI ​​server 20 generates example information showing appropriate medical record entries corresponding to the patient information and medical fee information output from the medical record creation support device S, and outputs it to the medical record entry example acquisition unit 12 of the processing unit 1 via the network NW and interface 4. As a result, the medical record entry example acquisition unit 12 outputs the acquired example information to the reflection / display control unit 13 of the processing unit 1.

[0039] Next, the reflection / display control unit 13, which has acquired the above example information, reflects the medical record entry corresponding to the example information acquired from the AI ​​server 20 as the patient's medical record, for example, by copying and pasting it, and displays the medical record including the reflection result on the display 5. At this time, the reflection / display control unit 13 may temporarily display the medical record entry corresponding to the example information acquired from the AI ​​server 20 on the display 5, and together with this, display a message indicating that the displayed medical record entry should be reflected as the patient's medical record, thereby prompting the physician to reflect the above medical record entry in the actual medical record.

[0040] Subsequently, if a physician performs a confirmation or modification operation on the medical record displayed on the display 5 by the reflection / display control unit 13 (a medical record reflecting the medical record entry corresponding to the example information described above) using the operation unit 3, the medical record content confirmation unit 14 of the processing unit 1 reflects the confirmation or modification operation in the content of the medical record and confirms it. After that, the recording control unit 15 of the processing unit 1 records the medical record with the confirmed content in, for example, the recording unit 2.

[0041] Furthermore, when an operation other than those described above is performed by a doctor or office worker using the operation unit 3, the operation unit 3 generates an operation signal corresponding to that operation and outputs it to the processing unit 1. As a result, the processing unit 1 executes the medical record creation support processing of the first embodiment in addition to the processing corresponding to the operation signal.

[0042] Next, in a medical record creation support system SS including a medical record creation support device S having the above-described configuration and operation, the medical record creation support processing of the first embodiment, which is executed mainly by the medical record creation support device S, will be explained in detail with reference to Figures 1 to 4.

[0043] In other words, the medical record creation support process of the first embodiment starts, for example, when a power switch (not shown) of the medical record creation support device S is turned on. Then, as shown in the corresponding flowchart in Figure 2, when the medical record creation support process starts, the acquisition unit 10 of the processing unit 1 first acquires the patient information and the medical fee information (step S1). Next, the medical fee calculation unit 11 of the processing unit 1 calculates the medical fee corresponding to the medical fee information input via the acquisition unit 10, temporarily displays the calculated medical fee on the display 5, and outputs the patient information and medical fee information input via the acquisition unit 10 to the AI ​​server 20 via the interface 4 and the network NW (step S2).

[0044] Next, the medical record entry example acquisition unit 12 of the processing unit 1 acquires entry example information from the AI ​​server 20, which shows an appropriate medical record entry example corresponding to the patient information and medical fee information output in step S2 (step S3). Subsequently, the reflection / display control unit 13 and the medical record content confirmation unit 14 of the processing unit 1 reflect the entry example information acquired from the AI ​​server 20 into the patient's medical record (step S4). After that, if a physician performs a confirmation or correction operation on the medical record (including the medical record entry corresponding to the above-mentioned entry example information) displayed on the display 5 by the reflection / display control unit 13 using the operation unit 3, the medical record content confirmation unit 14 reflects the confirmation or correction operation in the content of the medical record and confirms it (step S4). Subsequently, the recording control unit 15 of the processing unit 1 records the medical record with the confirmed content in, for example, the recording unit 2 (step S5). Subsequently, the processing unit 1 determines whether or not to terminate the medical record creation support process of the first embodiment by, for example, checking whether an operation to terminate the medical record creation support process of the first embodiment has been performed in the operation unit 3 (step S6). If the determination in step S6 is to terminate the medical record creation support process of the first embodiment (step S6: YES), the processing unit 1 terminates the medical record creation support process as is. On the other hand, if the determination in step S6 is to continue the medical record creation support process of the first embodiment for, for example, another patient (step S6: NO), the processing unit 1 returns to step S1 and continues the series of medical record creation support processes described above for that other patient.

[0045] As described above, according to the configuration and operation of the medical record creation support system SS of the first embodiment, patient information including the physical condition of the patient receiving insured medical treatment, medical fee information corresponding to the medical treatment provided to the patient, and example information corresponding to an example of how to write a medical record are obtained from the AI ​​server 20 and presented to the doctor or office staff (see steps S1 to S4 in Figure 2). Therefore, it is possible to present to the doctor or office staff a medical record entry that is appropriate for each patient and in chronological order, corresponding to the patient information and medical fee information. More specifically, for example, as shown in the example screen of display 5 in Figure 3, patient information B and medical fee information A can be output to the AI ​​server 20 and a medical record C containing entries corresponding to the example information obtained can be presented to the doctor or office staff. Then, as illustrated in Figure 4, an appropriate claim form RT including medical fee calculation items 100 that reflect the example entry in medical record C can be created. In this case, it is possible to create a medical record and claim form that correspond to the current physical condition of the patient (i.e., non-uniform and with fewer issues to be pointed out during medical fee calculation).

[0046] Furthermore, since the patient information output to the AI ​​server 20 includes at least one of the patient's age, gender, current height, current weight, smoking history, alcohol consumption history, allergy history, or current contraindicated medication information, it is possible to present a patient-specific medical record corresponding to the patient's current condition and medical fee information to a doctor or administrative staff member.

[0047] Furthermore, since the example information obtained from the AI ​​server 20 includes billing conditions based on patient information and medical fee information, and satisfies the billing conditions required for medical fee claims, it is possible to present doctors or administrative staff with more appropriate medical record entries.

[0048] Furthermore, since the information can be modified by the claimant based on the example (see Figure 2, Step S4), the medical record can be made even more appropriate.

[0049] (2) Second Embodiment Next, a second embodiment of the present invention will be specifically described using Figures 5 and 6, while reusing Figures 3 and 4 described above. Figure 5 is a block diagram showing the general configuration of the medical record creation support system of the second embodiment, and Figure 6 is a flowchart showing the medical record creation support process of the second embodiment. In Figures 5 and 6, components or steps similar to those of the medical record creation support system SS and medical record creation support process of the first embodiment are given the same component numbers or step numbers, and some detailed explanations are omitted.

[0050] While the medical record creation support system SS of the first embodiment primarily performed processing to support the creation of medical records, the medical record creation support system of the second embodiment performs processing to ensure consistency between the contents of the medical record and the contents of the medical claim form, in addition to the medical record creation support processing described above.

[0051] That is, as shown in Figure 5, the medical record creation support system SS2 of the second embodiment is composed of a medical record creation support device S of the second embodiment, an AI server 30 of the second embodiment, and a network NW such as the Internet that connects the medical record creation support device S and the AI ​​server 30 to enable the exchange of data.

[0052] In this case, the AI ​​server 30, like the AI ​​server 20 in the first embodiment, is an AI server that has been trained on the calculation method and / or application method of medical fees in insured medical care using a large amount of training data on the calculation method and / or application method of said medical fees. In addition, when the medical record creation support device S transmits the medical interview information, medical fee information and the claim information of the above-mentioned claim (i.e., claim information corresponding to the content of the claim) as described in the second embodiment later, the AI ​​server 30 has a function to check the consistency between the contents of the medical interview information, the medical fee information and the claim information (consistency of whether they are consistent or inconsistent) and send the consistency confirmation information, which is the result of the check, back to the medical record creation support device S. In addition to the above, when the AI ​​server 30 receives the above-mentioned medical interview information etc. from the medical record creation support device S, it also has the function of sending back example information to the medical record creation support device S, which is an appropriate (consistent as described above) example of a medical record corresponding to the medical interview information etc., and an example of a medical record that is considered appropriate for the patient at that time (i.e., a non-uniform example of a medical record). At this time, the example information includes the billing conditions based on patient information and medical fee information, and the contents that satisfy the billing conditions required for billing medical fees.

[0053] On the other hand, the medical record creation support device S of the second embodiment is composed of a processing unit 1, a recording unit 2 consisting of an HDD or SSD, an operation unit 3 consisting of a keyboard and mouse, an interface 4, and a display 5. The processing unit 1 is composed of an acquisition unit 10, a medical fee calculation unit 11, a medical record entry example acquisition unit 12, a reflection / display control unit 13, a medical record content confirmation unit 14, a recording control unit 15, and a scoring unit 16 of the second embodiment. In this case, the acquisition unit 10, the medical fee calculation unit 11, the medical record entry example acquisition unit 12, the reflection / display control unit 13, the medical record content confirmation unit 14, the recording control unit 15, and the scoring unit 16 may each be realized by hardware logic circuits constituting the processing unit 1, or they may be realized in software by the processing unit 1 reading and executing a program that corresponds to the medical record creation support processing of the second embodiment described later and is pre-recorded in the recording unit 2. Furthermore, the acquisition unit 10 corresponds to an example of a "specification information acquisition means," and the scoring unit 16 corresponds to an example of a "scoring means" of the present invention.

[0054] In the above configuration, the acquisition unit 10 of the processing unit 1 acquires the medical interview information, medical fee information, and claim information corresponding to the medical fee, which are the results of a medical interview with a patient receiving treatment from a doctor at a clinic equipped with a medical record creation support device S, when the doctor or their office staff inputs this information through operations on the operation unit 3. The medical interview information input at this time may include, for example, information similar to the patient information in the first embodiment, associated with identification information for identifying the patient from other patients. Subsequently, the medical fee calculation unit 11 of the processing unit 1 calculates the medical fee corresponding to the medical fee information input via the acquisition unit 10 using a predetermined calculation method, and temporarily displays the calculated medical fee on the display 5. In addition, the medical fee calculation unit 11 outputs the medical interview information, medical fee information, and claim information input via the acquisition unit 10 to the AI ​​server 30 via the interface 4 and the network NW. As a result, the AI ​​server 30 verifies the consistency of the contents of the medical interview information, medical fee information, and claim information output from the medical record creation support device S, and generates the consistency verification information as a result of this verification. In addition, the AI ​​server 30 generates example information showing appropriate medical record entries corresponding to the medical interview information, medical fee information, and claim information. Subsequently, the AI ​​server 30 outputs the generated consistency verification information and example information to the medical record example acquisition unit 12 of the processing unit 1 via the network NW and interface 4. As a result, the medical record example acquisition unit 12 outputs the acquired consistency verification information to the scoring unit 16 of the processing unit 1, and outputs the acquired example information to the reflection / display control unit 13 of the processing unit 1.

[0055] Next, the scoring unit 16, having acquired the consistency confirmation information, scores the degree of inconsistency in the contents of the medical interview information, medical fee information, and claim information using a pre-set scoring method if the consistency confirmation information indicates such inconsistencies, and outputs the score to the reflection / display control unit 13. The scoring unit 16 does not perform the scoring process if there are no inconsistencies.

[0056] On the other hand, the reflection / display control unit 13, which has acquired the above example information, reflects the medical record entry corresponding to the example information acquired from the AI ​​server 30 as the patient's medical record by, for example, copying and pasting it, and displays the medical record including the reflection result on the display 5. At this time, the reflection / display control unit 13 may temporarily display the medical record entry corresponding to the example information acquired from the AI ​​server 30 on the display 5, and together with this, display a message indicating that the displayed medical record entry should be reflected as the patient's medical record, thereby prompting the physician to reflect the above medical record entry in the actual medical record. Furthermore, if the reflection / display control unit 13 receives the above inconsistent score output from the score stock 16, it will also display that score on the display 5.

[0057] Subsequently, if a physician performs a confirmation or modification operation on the medical record displayed on the display 5 by the reflection / display control unit 13 (a medical record reflecting the medical record entry corresponding to the example information described above) using the operation unit 3, the medical record content confirmation unit 14 of the processing unit 1 reflects the confirmation or modification operation in the content of the medical record and confirms it. After that, the recording control unit 15 of the processing unit 1 records the medical record with the confirmed content in, for example, the recording unit 2.

[0058] Next, in the medical record creation support system SS2, which includes the medical record creation support device S having the above-described configuration and operation, the medical record creation support processing of the second embodiment, which is executed mainly by the medical record creation support device S, will be explained in detail with reference to Figures 3 to 6.

[0059] In other words, the medical record creation support process of the second embodiment starts, for example, when a power switch (not shown) of the medical record creation support device S is turned on. Then, as shown in the corresponding flowchart in Figure 6, when the medical record creation support process starts, the acquisition unit 10 of the processing unit 1 first acquires the above-mentioned medical interview information, the above-mentioned medical fee information, and the above-mentioned claim information (step S1). Next, the medical fee calculation unit 11 of the processing unit 1 calculates the above-mentioned medical fee corresponding to the medical fee information input via the acquisition unit 10, and temporarily displays the calculated medical fee on the display 5, and outputs the medical interview information, medical fee information, and claim information input via the acquisition unit 10 to the AI ​​server 30 via the interface 4 and the network NW (step S2).

[0060] Next, the medical record entry example acquisition unit 12 of the processing unit 1 acquires entry example information and consistency confirmation information from the AI ​​server 30 that show appropriate medical record entry examples corresponding to the medical interview information, medical fee information, and claim information output in step S2 above. The acquired consistency confirmation information is output to the scoring unit 16, and the acquired entry example information is output to the medical record content confirmation unit 14 (step S3). Subsequently, the scoring unit 16 of the processing unit 1 determines whether or not the consistency confirmation information from the AI ​​server 30 indicates that there is an inconsistency in the contents of the medical interview information, medical fee information, and claim information (step S4). If the consistency confirmation information indicates that there is no such inconsistency in the determination in step S4 (step S4: NO), the process proceeds to step S6, which will be described later. On the other hand, if the consistency confirmation information indicates that there is an inconsistency in the determination in step S4 (step S4: YES), the scoring unit 16 scores the degree of the inconsistency and outputs the score to the reflection / display control unit 13 (step S5), and proceeds to step S6, which will be described later. Subsequently, the reflection / display control unit 13 and the medical record content confirmation unit 14 of the processing unit 1 reflect the example information obtained from the AI ​​server 30 into the patient's medical record (step S6). Then, if a physician's confirmation or correction operation is performed on the medical record (including the medical record entry corresponding to the example information) displayed on the display 5 by the reflection / display control unit 13 using the operation unit 3, the medical record content confirmation unit 14 reflects the confirmation or correction operation in the content of the medical record and confirms it (step S6). If the score has been output from the scoring unit 16, the reflection / display control unit 13 displays the score on the display 5 in step S6. Subsequently, the recording control unit 15 of the processing unit 1 records the medical record containing the confirmed contents in, for example, the recording unit 2 (step S7). Subsequently, the processing unit 1 determines whether or not to terminate the medical record creation support process of the second embodiment by, for example, checking whether an operation to terminate the medical record creation support process of the second embodiment has been performed in the operation unit 3 (step S8).In the determination in step S8, if the medical record creation support process of the second embodiment is to be terminated (step S8: YES), the processing unit 1 terminates the medical record creation support process. On the other hand, in the determination in step S8, if the medical record creation support process of the second embodiment is to be continued for another patient, for example (step S8: NO), the processing unit 1 returns to step S1 and continues the series of medical record creation support processes described above for that other patient.

[0061] As described above, according to the configuration and operation of the medical record creation support system SS2 of the second embodiment, based on the results of checking the consistency between the medical interview information for a patient receiving insured medical treatment, the medical fee information corresponding to the medical treatment provided to the patient, and the claim information corresponding to the medical fee for the treatment, example information equivalent to an example of how to write a medical record corresponding to the medical interview information, the medical fee information, and the claim information is presented to the doctor or office staff (see steps S1 to S6 in Figure 6). Therefore, a medical record in a state where consistency is maintained between the medical interview information, the medical fee information, and the claim information, and an appropriate medical record entry for each patient corresponding to the medical interview information, the medical fee information, and the claim information can be presented to the doctor or office staff. More specifically, for example, as shown in the example screen of display 5 in Figure 3, a medical record C including an entry equivalent to the example information obtained by outputting medical interview information B, medical fee information A, and claim information (not shown) to the AI ​​server 30 can be presented to the doctor or office staff. As illustrated in Figure 4, it is possible to create an appropriate claim form RT that includes 100 medical fee calculation items that reflect the example entries in medical record C. In this case, it is possible to create individual medical records and claim forms that correspond to the patient's current physical condition (i.e., they are not uniform and have fewer issues to point out when submitting medical fee claims).

[0062] Furthermore, if consistency verification information obtained from the AI ​​server 30 indicates inconsistencies between the medical interview information, medical fee information, and claims information, example medical record entries will be presented to the doctor or administrative staff for each patient. This allows the claimant to be presented with a more appropriate medical record that ensures consistency between the medical interview information, medical fee information, and claims information.

[0063] Furthermore, if the consistency between medical interview information, medical fee information, and claims information is scored and presented to the physician or administrative staff for each patient (see Steps S5 and S6 in Figure 6), the physician or administrative staff can objectively recognize that consistency.

[0064] Furthermore, since the information can be modified by the claimant based on the example (see Figure 6, Step S6), the medical record can be made even more appropriate.

[0065] [Transformed form] Next, a modified form of the present invention will be described.

[0066] (1) First Transformation Form Firstly, as a first variant of the present invention, the medical record creation support process of each embodiment described above is configured to output patient information or interview information and medical fee information to AI server 20 or AI server 30. However, in addition to this, for example, when patient information or interview information and medical fee information are obtained, a medical record may be provisionally created by the physician, and the medical record information corresponding to the created medical record may be output to AI server 20 or AI server 30 along with the patient information and medical fee information, and example information corresponding to the medical record information, patient information or interview and medical fee information may be obtained. In this first variant, the example information corresponding to the patient information or interview information and medical fee information, as well as the medical record information, is presented to the physician or office worker, so that the physician or office worker can be presented with more appropriate medical record entries for each patient corresponding to the patient information or interview information and medical fee information, as well as the medical record created by the physician. Furthermore, since the contents of the medical record created by the doctor will be modified and presented by AI server 20 or AI server 30, it is possible to reduce the workload for doctors or administrative staff while providing them with more appropriate medical record entries for each patient.

[0067] (2) Second Transformation Form Next, as a second variant, the medical record creation support system SS of the first embodiment or the medical record creation support system SS2 of the second embodiment described above is configured to exchange various information with an AI server 20 or AI server 30 outside the medical record creation support device S via a network NW. However, alternatively, an AI processing unit equipped with medical record support functions equivalent to those of AI server 20 or AI server 30 may be provided inside the medical record creation support device. In this second variant, for example, the medical record creation support system can be realized as a system that is completed within a clinic.

[0068] (3) Third Transformation Form Finally, as a third variant, the above program, which corresponds to the flowchart shown in Figure 2 or Figure 6, can be recorded on a recording medium such as an optical disc or hard disk, or acquired via a network such as the Internet, and then read and executed by a general-purpose microcomputer, thereby allowing the microcomputer to function as the processing unit 1 of each embodiment. [Industrial applicability]

[0069] As described above, the present invention can be used in the field of medical record creation support systems, and particularly remarkable effects can be obtained when applied to support the creation of medical records by doctors or administrative staff who are busy due to reasons such as a large number of patients. [Explanation of Symbols]

[0070] 1 Processing Unit 2. Records Section 3 Control section 4 Interfaces 5 displays 10 Acquisition Department 11 Medical Fee Calculation Department 12. Medical Record Entry Example Acquisition Section 13 Reflection / Display Control Unit 14. Confirmation of Medical Record Contents 15 Recording Control Unit 16. Scoring Section 20, 30 AI servers 100 items for calculating medical fees S Medical Record Creation Support Device A Medical fee information B Patient information C Medical Record SS, SS2 Medical Record Creation Support System NW Network RT Receipt

Claims

1. A patient information acquisition means that acquires, for each patient, medical interview information that indicates the physical condition of a patient receiving insured medical treatment at the time of said insured medical treatment and includes identification information for identifying said patient from other patients, which is entered by a physician or administrative staff member involved in said insured medical treatment and corresponds to the content of the interview with said patient, A means for acquiring medical fee information that acquires medical fee information for each patient that corresponds to the insured medical treatment provided to the patient and that has been entered by the physician or the office worker, A statement information acquisition means for acquiring statement information for each patient that corresponds to the contents of the statement of medical fees prepared in accordance with the medical fees for the aforementioned insured medical treatment, Each of the acquired medical interview information, medical fee information, and output means for outputting the medical fee information to a learning device, wherein the learning device is (i) At least the calculation method of the medical fees in the aforementioned insured medical treatment and / or the application method of said medical fees have been trained using training data for said calculation method and / or application method, and (ii) Consistency confirmation information indicating whether the contents of each of the acquired medical interview information, medical fee information, and medical fee statement information are consistent with each other is generated and output based on the learning results of the training data, (iii) Based on the learning results of the training data, example information is generated and output that corresponds to the medical interview information, the medical fee information and the medical fee statement information, and that is equivalent to the content of an example medical record that is deemed appropriate for the medical treatment and the patient when the medical treatment was performed. The output means is a learning device, Information acquisition means for acquiring the outputted medical interview information, medical fee information, and the consistency confirmation information and example information generated / output by the learning device based on the medical fee information from the learning device, Based on the acquired consistency verification information, a presentation means presents the acquired example information to the physician who claims medical fees for the insured medical treatment for each patient, Equipped with, A medical record creation support device characterized in that the contents of the medical record of the patient who received the insured medical treatment are determined by the physician using the provided example information.

2. In the medical record creation support device according to claim 1, The presenting means is characterized by presenting the acquired example information to the physician for each patient when the consistency confirmation information indicates that there is an inconsistency between the contents of the medical interview information, the medical fee information, and the medical fee statement information.

3. In the medical record creation support device according to claim 1, The medical record creation support device is characterized in that the presentation means further comprises a scoring means that scores the degree of consistency based on the consistency confirmation information using a pre-set scoring method and presents it to the physician for each patient.

4. In the medical record creation support device according to claim 1, The system further comprises a means for acquiring medical record information that acquires medical record information corresponding to the contents of a medical record created by the physician for the patient based on the aforementioned medical interview information and medical fee information. The output means outputs each of the acquired medical interview information, medical fee information, medical fee statement information, and medical record information to the learning device. A medical record creation support device characterized in that the information acquisition means acquires the generated consistency confirmation information and example information from the learning device in correspondence with the medical interview information, the medical fee information, the medical fee statement information, and the medical record information.

5. In the medical record creation support device according to claim 4, The presenting means is a medical record creation support device characterized by modifying the medical record information using the acquired example information and presenting the modified medical record information to the physician.

6. In a medical record creation support device according to any one of claims 1 to 5, A medical record creation support device further comprising a reception means for receiving a correction operation of the medical record by the physician based on the provided example information.

7. A medical record creation support method performed in a medical record creation support device comprising: patient information acquisition means; medical information acquisition means; specification information acquisition means; output means; information acquisition means; and presentation means, A patient information acquisition step involves acquiring, for each patient, the patient information acquisition means a patient information acquisition method that includes medical interview information indicating the physical condition of a patient receiving insured medical treatment at the time of such treatment and including identification information for identifying the patient from other patients, which is entered by a physician or administrative staff member involved in the insured medical treatment and corresponds to the content of the medical interview with the patient. A medical fee information acquisition step, which involves acquiring medical fee information for each patient, corresponding to the insured medical treatment provided to the patient and entered by the physician or office worker, using the medical information acquisition means; A procedure for acquiring medical fee statement information for each patient using the medical fee statement information acquisition means, which includes: An output step in which each of the acquired medical interview information, medical fee information, and medical fee information is output to a learning device by the output means, wherein the learning device (i) At least the calculation method of the medical fees in the aforementioned insured medical treatment and / or the application method of said medical fees have been trained using training data for said calculation method and / or application method, and (ii) Consistency confirmation information indicating whether the contents of each of the acquired medical interview information, medical fee information, and medical fee statement information are consistent with each other is generated and output based on the learning results of the training data, (iii) Based on the learning results of the training data, example information is generated and output that corresponds to the medical interview information, the medical fee information and the medical fee statement information, and that is equivalent to the content of an example medical record that is deemed appropriate for the medical treatment and the patient when the medical treatment was performed. The output process is a learning device, An information acquisition step in which each of the output medical interview information, medical fee information, and the consistency confirmation information and example information generated / output by the learning device based on the medical fee information are acquired from the learning device by the information acquisition means; Based on the acquired consistency verification information, the acquisition example information is presented to the physician who claims medical fees for the insured medical treatment for each patient using the presentation means, in a presentation step, Includes, A method for supporting the creation of medical records, characterized in that the contents of the medical record of the patient who received the insured medical treatment are determined by the physician using the provided example information.

8. The computer included in the medical record creation support device A patient information acquisition means that acquires, for each patient, medical interview information that indicates the physical condition of a patient receiving insured medical treatment at the time of such treatment and includes identification information for distinguishing the patient from other patients, which is entered by a physician or administrative staff member involved in the insured medical treatment and corresponds to the content of the interview with the patient. A means for acquiring medical fee information that corresponds to the insured medical treatment provided to the patient and acquires medical fee information entered by the physician or the office worker for each patient. A statement information acquisition means for acquiring statement information for each patient that corresponds to the contents of the statement of medical fees prepared in accordance with the medical fees for the aforementioned insured medical treatment. Each of the acquired medical interview information, medical fee information, and output means for outputting the medical fee information to a learning device, wherein the learning device is (i) At least the calculation method of the medical fees in the aforementioned insured medical treatment and / or the application method of said medical fees have been trained using training data for said calculation method and / or application method, and (ii) Consistency confirmation information indicating whether the contents of each of the acquired medical interview information, medical fee information, and medical fee statement information are consistent with each other is generated and output based on the learning results of the training data, (iii) Based on the learning results of the training data, example information is generated and output that corresponds to the medical interview information, the medical fee information and the medical fee statement information, and that is equivalent to the content of an example medical record that is deemed appropriate for the medical treatment and the patient when the medical treatment was performed. The output means is a learning device. Information acquisition means for acquiring the outputted medical interview information, medical fee information, and the consistency confirmation information and example information generated / output by the learning device based on the medical fee information from the learning device, and Based on the acquired consistency verification information, a presentation means presents the acquired example information to the physician who claims medical fees for the insured medical treatment for each patient. A medical record creation support program that functions as such, A medical record creation support program characterized in that the contents of the medical record of the patient who received the insured medical treatment are determined by the physician using the provided example information.

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