第2章の章末問題でやったカルテ例1をOpenDolphinに入力してORCAで診療報酬明細書を作成し、模範解答と比較しなさい。を実際にやってみたのでまとめておく。
OpenDolphinで過去にさかのぼってカルテは作成できるか？
その前に標題について考える。
カルテ例1は、平成29年4月10日（耳鼻科）、4月17日（耳鼻科と内科）の3日間の診療記録である。したがって過去にさかのぼってカルテを作成しなければならない。
医事会計システムORCAはそれができた。では、電子カルテシステムであるOpenDolphinにそれができるのだろうか？電子カルテなのだから、日付を変える（実際の診療日でない過去の日付に変える）のはカルテの改ざんに当たらないのか・・・。そういう事情があってかどうかは知らないが、OpenDolphinでは日付を変えてカルテを作成する機能はなさそうである。
そこで、カルテ例1の初回の診察日（4/10 耳鼻科）のみ、当日日付で入力するものとする。
診療科の設定と患者の選択
1) OpenDolphinにログインし、メニューから［ツール］→［プロフィール］を選んでこの医師の診療科を「耳鼻いんこう科」に変更する。
 |
| 図1．プロフィール画面 |
2) ORCAで 患者受付を行う。
 |
| 図2．ORCAの患者受付画面 |
3) OpenDolphinの受付画面にORCAで受け付けた患者が表示されたら、その患者をマウスの右ボタンでクリックして表示されるメニューから「カルテを開く」を選択する。
 |
| 図3．患者受付画面 |
カルテの作成
下図に示す画面（インスペクタ画面という）が開いたら、メニューにある［カルテ作成］ボタン（［参照］タブの真上にある黄色い星のついたドキュメントアイコン）をクリックする。
 |
| 図4．インスペクタ画面 |
すると下図に示す確認画面が出るので、そのまま［OK］ボタンをクリックする。
 |
| 図5．新規カルテ画面 |
下図に示す白紙のカルテ画面が現れたら、カルテ例1の4/10分（耳鼻科）の経過記録とオーダを入力する。
 |
| 図6．白紙のカルテ画面 |
 |
| 図7．入力し終えたカルテ画面 |
 |
| 図8．ドキュメント保存 |
［タイトル］に相応しい文字列を入力して［保存］を押す。
医事会計システム（ORCA）を確認
電子カルテシステムから入力したオーダが医事会計システムにどのように反映されているかを確認するためにORCAの［診療行為］画面を開いて当該患者のIDを入力した。
図9にその画面を示す。
 |
| 図9．医事会計システムORCAの診療行為画面 |
- 科コード、担当医はOK
- 再診料（72点）がない
- B-V（血液採取「1」静脈25点）がない
- 「院内」処方になっている
- 各種加算自動発生されてない
- 明細書発行体制等加算（1点）
- 時間外対応加算２（3点）
- 一般名処方加算（3点）
- 検体検査判断料がない
- 血液学的検査判断料（125点）
- 免疫学的検査判断料（144点）
- 処方せん料（68点）
したがって、以下の項目については手入力した。
- 再診料（72点）
- 明細書発行体制等加算（1点）
- 時間外対応加算２（3点）
- 一般名処方加算（3点）
- B-V（血液採取「1」静脈25点）
これらを手入力して［登録］ボタンを押すと、「警告！一般名処方加算（処方せん料）の対象薬剤がありません」という警告メッセージが出たので、オロパタジン塩酸塩とクロモグリク酸ナトリウムをジェネリック医薬品に変更してから［登録］ボタンを押すと警告が出なくなった。単に処方入力を間違っていただけである。
以上より、電子カルテシステムでオーダを入力して、それをORCAへ送信しても、かなりの項目を手入力しなければならないことがわかった。
レセプトの作成
不足分を手入力後 レセプトを作成した。図10に作成したレセプトを示す。
 |
| 図10．レセプト |
パケットキャプチャ
OpenDolphinの受付画面で患者を選んでカルテ画面を開くときのOpenDolphinクライアントとサーバ間の通信をキャプチャした。
その結果、3つのセッションを取得できた。
セッション１（受診履歴）
リスト1は 最初のセッションをキャプチャした結果である。使用するサーバ側のPort番号は8080で、プロトコルはHTTPである。
GET /dolphin/openSource/karte/24,2008-12-11%2012:00:00 HTTP/1.1
Accept: application/json
Accept-Encoding: gzip, deflate
password: d844211bc2d60c9dea151d0b3abb6678
userName: 1.3.6.1.4.1.9414.70.1:DR0002
Host: 172.16.111.217:8080
Connection: Keep-Alive
HTTP/1.1 200 OK
Connection: keep-alive
X-Powered-By: Undertow/1
Server: WildFly/9
Content-Type: application/json
Content-Length: 1198
Date: Tue, 11 Dec 2018 03:03:43 GMT
{
"patientVisits": [
"2018-04-10T10:44:24",
"2018-12-10T06:18:44",
"2018-12-09T06:27:19"
],
"docInfoList": [
{
"hasRp": true,
"hasTreatment": false,
"hasLaboTest": true,
"hasMark": false,
"sendLabtest": false,
"sendMml": false,
"hasImage": false,
"title": "耳鼻科（4/10）",
"facilityName": null,
"patientId": null,
"department": "27",
"firstConfirmDate": 1544494704394,
"confirmDate": 1544494704394,
"departmentDesc": "耳鼻いんこう科,27,医師 二郎,10002,JPN332020100008",
"parentPk": 0,
"docId": "9afe11a0ac106c2c586f49aafe7e4c86",
"sendClaim": false,
"versionNumber": "1.0",
"parentIdRelation": null,
"docType": "karte",
"purpose": "recode",
"healthInsurance": "31",
"healthInsuranceDesc": "31 国家共済",
"healthInsuranceGUID": "75923d6f-a338-4cd5-8cd1-ce60377224e0",
"claimDate": 1544494668866,
"patientGender": null,
"patientName": null,
"departmentCodeSys": null,
"docPk": 72,
"purposeDesc": null,
"purposeCodeSys": null,
"healthInsuranceCodeSys": null,
"versionNotes": null,
"parentId": null,
"parentIdDesc": null,
"parentIdCodeSys": null,
"labtestOrderNumber": null,
"pvthealthInsuranceModel": null,
"createrLisence": null,
"status": "F"
}
],
"memoList": null,
"lastDocDate": 1544494704394,
"created": "2018-12-08",
"allergies": null,
"heights": null,
"weights": null,
"id": 26
}
リスト1．受診履歴
1行目はクライアントがリクエスト行に設定したGETコマンドである。「24,2008-12-11%2012:00:00」というキーを指定してRESTful APIを使って患者の受診履歴を要求している。
先頭の「24」は患者を識別するための内部キーかもしれない。カンマに続く「2008-12-11%2012:00:00」はタイムスタンプのようである。「2008/12/11 12:00:00」という意味であろうか？
しかし、カルテを入力したのは2018/12/11である。西暦年が10年も違う。
サーバからのレスポンスはJSON形式になっている。「patientVisits」は見るからに受診日履歴である。年月日時分秒まで記録されている。
「docInfoList」はその配列要素がカルテ概略のようだ。「docId」でカルテと紐づけているのかもしれない。それにしても「patientId」がnullというのは奇妙だ。
セッション2（排他制御？）
2番目のセッションをリスト2に示す。
PUT /dolphin/openSource/chartEvent/event HTTP/1.1
Accept-Encoding: gzip, deflate
Content-Type: application/json
password: d844211bc2d60c9dea151d0b3abb6678
userName: 1.3.6.1.4.1.9414.70.1:DR0002
Content-Length: 293
Host: 172.16.111.217:8080
Connection: Keep-Alive
{
"state": 1,
"patientModel": null,
"ownerUUID": "DR0002:250bb875-b660-4033-8656-4074e0dace83",
"byomeiCountToday": 0,
"byomeiCount": 0,
"facilityId": "1.3.6.1.4.1.9414.70.1",
"memo": null,
"issuerUUID": "DR0002:250bb875-b660-4033-8656-4074e0dace83",
"patientVisitModel": null,
"eventType": 0,
"ptPk": 24,
"pvtPk": 0
}
HTTP/1.1 200 OK
Connection: keep-alive
X-Powered-By: Undertow/1
Server: WildFly/9
Content-Type: application/json
Content-Length: 1
Date: Tue, 11 Dec 2018 03:03:43 GMT
1
リスト2．排他制御と思われる通信データ
リスト1と違ってクライアントはPUTメソッドを送っている。RESTful APIではPUTメソッドは更新を意味する。何らかの情報の更新をサーバにリクエストしているものと思われる。
リクエストメッセージのボディ部にあるJSON形式のデータを見ると「ptPk」に「24」という値が設定されている。これが患者を識別するための内部キーであれば、この通信は患者情報を他のプロセスには利用させないようにロックしているのかもしれない。
セッション3
リスト3に示すように、最後のセッションは、サーバがとても長いデータを返送してくる。
GET /dolphin/openSource/karte/documents/72 HTTP/1.1
Accept: application/json
Accept-Encoding: gzip, deflate
password: d844211bc2d60c9dea151d0b3abb6678
userName: 1.3.6.1.4.1.9414.70.1:DR0002
Host: 172.16.111.217:8080
Connection: Keep-Alive
HTTP/1.1 200 OK
Connection: keep-alive
X-Powered-By: Undertow/1
Server: WildFly/9
Transfer-Encoding: chunked
Content-Type: application/json
Date: Tue, 11 Dec 2018 03:03:43 GMT
{
"list": [
{
"modules": [
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"started": 1544494704394,
"ended": null,
"confirmed": 1544494704394,
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"linkId": 0,
"linkRelation": null,
"recorded": 1544494704394,
"userModel": {
"memberType": null,
"registeredDate": null,
"licenseModel": null,
"facilityModel": null,
"sirName": null,
"givenName": null,
"commonName": null,
"departmentModel": null,
"memo": null,
"email": null,
"orcaId": null,
"useDrugId": null,
"roles": null,
"userId": null,
"password": null,
"id": 10
},
"karteBean": {
"patientVisits": null,
"docInfoList": null,
"memoList": null,
"lastDocDate": null,
"created": null,
"allergies": null,
"heights": null,
"weights": null,
"id": 26
},
"moduleInfoBean": {
"stampNumber": 0,
"stampName": "progressCourse",
"stampRole": "soaSpec",
"entity": "progressCourse"
},
"status": "F",
"id": 73
},
{
"started": 1544494704394,
"ended": null,
"confirmed": 1544494704394,
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"linkId": 0,
"linkRelation": null,
"recorded": 1544494704394,
"userModel": {
"memberType": null,
"registeredDate": null,
"licenseModel": null,
"facilityModel": null,
"sirName": null,
"givenName": null,
"commonName": null,
"departmentModel": null,
"memo": null,
"email": null,
"orcaId": null,
"useDrugId": null,
"roles": null,
"userId": null,
"password": null,
"id": 10
},
"karteBean": {
"patientVisits": null,
"docInfoList": null,
"memoList": null,
"lastDocDate": null,
"created": null,
"allergies": null,
"heights": null,
"weights": null,
"id": 26
},
"moduleInfoBean": {
"stampNumber": 1,
"stampName": "末梢血液一般",
"stampRole": "p",
"entity": "physiologyOrder"
},
"status": "F",
"id": 74
},
{
"started": 1544494704394,
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"linkId": 0,
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"recorded": 1544494704394,
"userModel": {
"memberType": null,
"registeredDate": null,
"licenseModel": null,
"facilityModel": null,
"sirName": null,
"givenName": null,
"commonName": null,
"departmentModel": null,
"memo": null,
"email": null,
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},
"karteBean": {
"patientVisits": null,
"docInfoList": null,
"memoList": null,
"lastDocDate": null,
"created": null,
"allergies": null,
"heights": null,
"weights": null,
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},
"moduleInfoBean": {
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"stampName": "クロモグリク酸Ｎａ点鼻液２％「ファイザー」 １９０ｍｇ９．５ｍＬ",
"stampRole": "p",
"entity": "medOrder"
},
"status": "F",
"id": 79
},
{
"started": 1544494704394,
"ended": null,
"confirmed": 1544494704394,
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"linkId": 0,
"linkRelation": null,
"recorded": 1544494704394,
"userModel": {
"memberType": null,
"registeredDate": null,
"licenseModel": null,
"facilityModel": null,
"sirName": null,
"givenName": null,
"commonName": null,
"departmentModel": null,
"memo": null,
"email": null,
"orcaId": null,
"useDrugId": null,
"roles": null,
"userId": null,
"password": null,
"id": 10
},
"karteBean": {
"patientVisits": null,
"docInfoList": null,
"memoList": null,
"lastDocDate": null,
"created": null,
"allergies": null,
"heights": null,
"weights": null,
"id": 26
},
"moduleInfoBean": {
"stampNumber": 7,
"stampName": "progressCourse",
"stampRole": "pSpec",
"entity": "progressCourse"
},
"status": "F",
"id": 80
}
],
"started": 1544494704394,
"ended": null,
"confirmed": 1544494704394,
"linkId": 0,
"linkRelation": null,
"recorded": 1544494704394,
"userModel": {
"memberType": null,
"registeredDate": null,
"licenseModel": null,
"facilityModel": null,
"sirName": null,
"givenName": null,
"commonName": "医師 二郎",
"departmentModel": null,
"memo": null,
"email": null,
"orcaId": null,
"useDrugId": null,
"roles": null,
"userId": null,
"password": null,
"id": 10
},
"karteBean": {
"patientVisits": null,
"docInfoList": null,
"memoList": null,
"lastDocDate": null,
"created": null,
"allergies": null,
"heights": null,
"weights": null,
"id": 26
},
"docInfoModel": {
"hasRp": true,
"hasTreatment": false,
"hasLaboTest": true,
"hasMark": false,
"sendLabtest": false,
"sendMml": false,
"hasImage": false,
"title": "耳鼻科（4/10）",
"facilityName": null,
"patientId": null,
"department": "27",
"firstConfirmDate": 1544494704394,
"confirmDate": 1544494704394,
"departmentDesc": "耳鼻いんこう科,27,医師 二郎,10002,JPN332020100008",
"parentPk": 0,
"docId": "9afe11a0ac106c2c586f49aafe7e4c86",
"sendClaim": false,
"versionNumber": "1.0",
"parentIdRelation": null,
"docType": "karte",
"purpose": "recode",
"healthInsurance": "31",
"healthInsuranceDesc": "31 国家共済",
"healthInsuranceGUID": "75923d6f-a338-4cd5-8cd1-ce60377224e0",
"claimDate": 1544494668866,
"patientGender": null,
"patientName": null,
"departmentCodeSys": null,
"docPk": 72,
"purposeDesc": null,
"purposeCodeSys": null,
"healthInsuranceCodeSys": null,
"versionNotes": null,
"parentId": null,
"parentIdDesc": null,
"parentIdCodeSys": null,
"labtestOrderNumber": null,
"pvthealthInsuranceModel": null,
"createrLisence": null,
"status": "F"
},
"attachment": null,
"schema": null,
"status": "F",
"id": 72
}
]
}
リスト3．カルテ要求＆返送
これは、クライアントのカルテ要求に対するサーバのカルテ返送だと思われる。
1行目のRESTful APIでクライアントはid=72のカルテ（document）をサーバに要求している。この72という値はセッション1のサーバからのレスポンスJSONデータの中に「docPk」という属性で含まれていた。おそらくこれを要求したのであろう。
これに対してサーバは非常に長いメッセージを返している。 このメッセージの構造を見てみると、リスト4に示す枠組みからなっている。
{
"list": [
{
"modules": [
{...①...},
{...②...},
{...③...},
{...④...},
{...⑤...},
{...⑥...},
{...⑦...},
{...⑧...}
],
"started": 1544494704394,
"ended": null,
"confirmed": 1544494704394,
"linkId": 0,
"linkRelation": null,
"recorded": 1544494704394,
"userModel": {...⑨...},
"karteBean": {...⑩...},
"docInfoModel": {...⑪...},
"attachment": null,
"schema": null,
"status": "F",
"id": 72
}
]
}
リスト4. カルテの構造
