Association of data entries with patient records, customized hospital discharge instructions, and charting by exception for a computerized medical record system
First Claim
1. Apparatus for associating an unassociated patient record with the corresponding patient, comprising:
- A. a data processor programmed for accessing an unassociated patient record not associated with a unique person;
identifying at least one of direct and indirect patient identification data stored in said unassociated patient record;
accessing a database of at least one known patient record unambiguously associated with a known patient; and
comparing said direct or indirect patient identification data from said unassociated patient record to corresponding data in said known patient record to identify a set of one or more known patients that correlate with said direct or indirect patient identification data;
B. a display for displaying members of said set of one or more known patients; and
C. a choice input for selecting, from the display of members of said set, a member associated with said unassociated patient record.
4 Assignments
0 Petitions
Accused Products
Abstract
Apparatus and a method for associating an electronic patient record with the corresponding patient are described. A data processor accesses a patient record not associated with a unique person and compares the patient identification data to corresponding data in a known patient record to identify a set of likely matching patients. An input is provided for selecting a matching patient. Also disclosed is apparatus for providing customized patient discharge instructions relating information in the electronic patient record to patient-specific discharge instructions. A data processor inserts the patient specific instructions into draft instructions, thereby producing patient-specific discharge instructions. An updated version of charting by exception is disclosed, using macros to positively record data on a medical record that is not specifically marked on a template by the attending medical professional. Also described is an apparatus for translating a visual documentation language, communicating specific medical concepts in a highly compact form, to clinically relevant English, enhancing the usability of a pen/digital camera combination for data entry.
48 Citations
70 Claims
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1. Apparatus for associating an unassociated patient record with the corresponding patient, comprising:
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A. a data processor programmed for accessing an unassociated patient record not associated with a unique person;
identifying at least one of direct and indirect patient identification data stored in said unassociated patient record;
accessing a database of at least one known patient record unambiguously associated with a known patient; and
comparing said direct or indirect patient identification data from said unassociated patient record to corresponding data in said known patient record to identify a set of one or more known patients that correlate with said direct or indirect patient identification data;
B. a display for displaying members of said set of one or more known patients; and
C. a choice input for selecting, from the display of members of said set, a member associated with said unassociated patient record. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29)
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- 30. Apparatus for associating a patient with an electronic record, comprising in combination an identification device for addressing an on-patient identifier to identify the patient and a handwriting encoder that makes an electronic record of handwriting as it is written.
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32. A method for associating an unassociated patient record with the corresponding patient, comprising:
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A. accessing an unassociated patient record not associated with a unique person;
B. identifying at least one of direct and indirect patient identification data stored in said unassociated patient record;
C. accessing a database of at least one known patient record unambiguously associated with at least one known patient;
D. comparing said direct or indirect patient identification data from said unassociated patient record to corresponding data in said known patient record to identify a set of one or more known patients that correlate with said direct or indirect patient identification data;
E. displaying members of said set of one or more known patients; and
F. selecting, from the display of members of said set, a member corresponding to said unassociated patient record. - View Dependent Claims (33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53)
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54. Apparatus for providing customized patient discharge instructions, comprising:
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A. an electronic patient record stored in a data storage medium, said record including data about at least one of the patient'"'"'s personal information, complaints, symptoms, medical history, and diagnosis;
B. a discharge instruction format stored in a data storage medium comprising general instructions to be given all patients having a particular complaint and having at least one customizable field for patient-specific instructions to be inserted;
C. a database relating information in said electronic patient record to patient-specific discharge instructions to be added to said customizable fields D. a data processor for revising said discharge instruction format by querying said electronic patient record to identify patient-specific instructions and inserting said patient specific instructions in one or more of said customizable fields, thereby producing patient-specific discharge instructions; and
E. an output device for outputting said patient-specific discharge instructions. - View Dependent Claims (55, 56, 57)
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58. A medical chart template comprising:
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a. a multiplicity of recording areas for entering predetermined categories of data reflecting the patient'"'"'s condition; and
b. a charting by exception recording area for entering an indication that at least one predetermined category of data on the template has been reviewed, and is normal, unless an entry other than normal has been recorded in the corresponding recording area for said at least one predetermined category. - View Dependent Claims (59, 60, 61, 62, 63, 64, 65, 66)
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67. A method of recording medical information on the electronic medical record for a patient, comprising:
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a. providing a medical chart template comprising (i) a multiplicity of recording areas for entering predetermined categories of patient data reflecting the patient'"'"'s condition; and
(ii) a charting by exception recording area for indicating that at least one predetermined category of patient data on the template has been reviewed, and is normal;
b. examining a patient to determine which predetermined categories of data identified on the template are normal and which are abnormal;
c. for any predetermined category of data identified on the template that is found to be abnormal in said examining step, entering data on said template documenting the abnormality;
d. entering an indication in said charting by exception recording area that multiple predetermined categories of data that have not been documented on the template as abnormal should be documented as normal;
e. incorporating said data as one or more entries in the patient'"'"'s medical record documenting said abnormal data; and
f. incorporating said indication as one or more entries in the patient'"'"'s medical record documenting said normal data. - View Dependent Claims (68, 69, 70)
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Specification