Medical records, documentation, tracking and order entry system
First Claim
1. A medical records, documentation, tracking and order entry system, comprising single or multiple fault tolerant file servers with single or multiple fault tolerant backup servers, with each server having either standard hard drives or redundant array of independent drives, a communications server(s) linked to each of the file servers for receiving incoming transcription and for remote reception of software, maintenance and system updates from a software vendor, a network having a hub connected to the file servers, peripheral terminals connected to the network in a star configuration with the hub, the peripheral terminals having individual central processing units with hard disks, touch screens, monitor, keyboards and mouses connected to the CPU'"'"'s, software residing in the communication server(s), in the file servers, and in the peripheral CPU'"'"'s for receiving patient data in the peripheral CPU'"'"'s via the touch screens, mouses, and keyboards and for storing the patient data in the peripheral CPU'"'"'s and the file servers;
- and a distributed dictation system having inputs adjacent the CPU'"'"'s, a transcription system for receiving dictation from the inputs and connected to the communication server(s) for transmitting transcribed dictations to the communications server(s) and placing the transcribed dictations in an electronic storage bin for transferring the dictated transcriptions to the file servers, storing the dictated transcriptions in the file servers as text associated with the patient data for particular patients, printers connected to the network for printing reports on individual patients and system management reports of system operations, doctor related activities, nursing related activities and patient statistics.
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Abstract
The new system provides: automatic incorporation of dictated text; medical records summary generation in medical English text; parsing dictation to data; prephrased text; automatic generation of medical record as consequence of data entry; automatic notation of allergies, significant medical conditions and pregnancy; pregnancy linking, automatically; security card—close on pull; multi-look grease board; outstanding orders listing for all patients in the department; department layout; room selection excludes occupied rooms; nurses notes to text; nurses notes from physician orders to nurses; lab request screen shows all previously ordered labs; therapeutics; ACLS recording; lacerations; doctor specific prescriptions and medication orders; review of systems; coding level alerts differential diagnosis—filter to sex and age; diagnosis—fractures to text; doctor interval reexamination; patient instructions predicated on what was done; patient instruction video on demand; patient informed consent video on demand; video teleconferencing; electronic signatures; automatic backup and incremental backup with system on-line; critical management reports; and automatic research data extraction.
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Citations
36 Claims
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1. A medical records, documentation, tracking and order entry system, comprising single or multiple fault tolerant file servers with single or multiple fault tolerant backup servers, with each server having either standard hard drives or redundant array of independent drives, a communications server(s) linked to each of the file servers for receiving incoming transcription and for remote reception of software, maintenance and system updates from a software vendor, a network having a hub connected to the file servers, peripheral terminals connected to the network in a star configuration with the hub, the peripheral terminals having individual central processing units with hard disks, touch screens, monitor, keyboards and mouses connected to the CPU'"'"'s, software residing in the communication server(s), in the file servers, and in the peripheral CPU'"'"'s for receiving patient data in the peripheral CPU'"'"'s via the touch screens, mouses, and keyboards and for storing the patient data in the peripheral CPU'"'"'s and the file servers;
- and a distributed dictation system having inputs adjacent the CPU'"'"'s, a transcription system for receiving dictation from the inputs and connected to the communication server(s) for transmitting transcribed dictations to the communications server(s) and placing the transcribed dictations in an electronic storage bin for transferring the dictated transcriptions to the file servers, storing the dictated transcriptions in the file servers as text associated with the patient data for particular patients, printers connected to the network for printing reports on individual patients and system management reports of system operations, doctor related activities, nursing related activities and patient statistics.
- 2. A method of patient record documentation, tracking and order entry, comprising providing software in file servers, providing software from the file servers through a network hub and network to multiple CPU'"'"'s, entering patient data in the multiple CPU'"'"'s by touch screens, mouses and keyboards in response to data entry screens on monitors connected to the CPU'"'"'s, transferring the patient data from the CPU'"'"'s to the file servers, dictating portions of the record that are unique to particular patients, transmitting the dictation over lines to a transcription center, transcribing the dictation and transmitting the dictation transcriptions to a communication server(s), feeding the dictation transcriptions to the file servers as text, storing the text with the tabled data on particular patients in the file servers, storing word and sentence generation and coordination software in the peripheral CPU'"'"'s, displaying on the peripheral CPU monitors text sentences in medical English text generated from patient data by the generation software, as combined with the text from the dictation transcriptions assembled as summaries, and providing the text summaries from the peripheral CPU'"'"'s to printers via the network for generation of printed patient textual reports.
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7. The method of patient record documentation, tracking and order entry, comprising logging on to a peripheral CPU, displaying the user'"'"'s name and the active patient list “
- grease board”
, and showing room location, patient'"'"'s name, patient'"'"'s physician, nursing orders, patient priority and elapsed time of stay, and status of assignment of nurse and physician, ordering of X-rays, labs, tests, nurses'"'"' orders, records, dictation and vital signs. - View Dependent Claims (8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36)
- grease board”
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15. The method of patient record documentation tracking and order entry, comprising entering patient data in one of plural peripheral CPU'"'"'s by touching a touch screen or by moving and clicking a mouse, entering specific patient complaints by touch screen or mouse, and automatically generating potential differential diagnosis from a specific patient complaint according to sex and age in the patient data.
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23. The method of video instruction on demand, comprising storing prepared video patient instructions in a file server, preselecting the video instructions according to complaint, sex, age, prescriptions and procedures, selecting video instructions from preselected video instructions and displaying the selected instructions, whereby video patient instructions can be provided on the screen of any terminal CPU to instruct patients in the proper care of and information about medical conditions.
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25. The method of medical language generation from data, comprising storing sentences and phrases related to medical data in peripheral CPU'"'"'s, inputting patient data, transferring patient data to file servers and tabling patient data, transferring the tabled patient data to the CPU'"'"'s and compiling sentences and paragraphs in the CPU'"'"'s from the stored sentences and phrases and the patient data, whereby stored medical facts are converted into sentence structure.
Specification