Association of data entries with patient records, customized hospital discharge instructions, and charting by exception for a computerized medical record system

• US 20060036472A1
• Filed: 07/15/2005
• Published: 02/16/2006
• Est. Priority Date: 07/16/2004
• Status: Active Grant

• Current Assignee: Picis Incorporated (Constellation Software Incorporated)
• Original Assignee: Picis Incorporated (Constellation Software Incorporated)
• Inventors: Crockett, Mark D.
• Granted Patent: US 8,392,216 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients

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.

Claims

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.

2. The apparatus of claim 1, further comprising a digital encoder for capturing said unassociated patient record.

3. The apparatus of claim 2, wherein said digital encoder is a digital camera programmed to capture a series of images from an adjacent position-encoded surface representing the path of movement of said encoder in proximity to the position-encoded surface.

4. The apparatus of claim 3, wherein said digital encoder further comprises a marking instrument positioned for marking the position-encoded surface as said encoder is moved in proximity to said position-encoded surface.

5. The apparatus of claim 2, wherein said digital encoder further comprises a position recorder operatively connected to add to said unassociated patient record data indicating where the digital encoder is located while it is being used to record data in the unassociated record.

6. The apparatus of claim 2, wherein said digital encoder further comprises a time recorder operatively connected to add to said unassociated patient record time-of-day data indicating when the digital encoder is being used to record data in the unassociated record.

7. The apparatus of claim 1, further comprising a patient data input for receiving patient identification data.

8. The apparatus of claim 7, wherein said patient data input receives direct patient identification data.

9. The apparatus of claim 7, wherein said patient data input receives indirect patient identification data.

10. The apparatus of claim 1, further comprising programming in said data processor for prioritizing the members of said set of one or more known patients presented by said display according to the calculated probability that each said member of said set should be associated with said unassociated patient record.

11. The apparatus of claim 10, further comprising programming in said data processor for displaying, in connection with at least one member of said set of known patients presented by said display, the calculated probability that the member of said set connected with said probability should be associated with said unassociated patient record.

12. The apparatus of claim 1, wherein said data processor comprises optical character recognition programming to extract data from writing in said unassociated patient record.

13. The apparatus of claim 1, wherein said data processor comprises handwriting recognition programming to extract data from handwriting in said unassociated patient record.

14. The apparatus of claim 1, wherein said direct patient identification data is selected from a first name, a surname, a middle name, a nickname, a pseudonym, a name suffix, a patient number, a social security number, a photograph, a signature, a fingerprint, body scan data, a cell phone number, patient wristband data, or combinations of these.

15. The apparatus of claim 14, wherein said data processor is programmed for

identifying at least one item of direct patient identification data and at least one item of indirect patient identification data stored in said unassociated patient record;

and

comparing said direct and 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.

16. The apparatus of claim 15, wherein said indirect patient identification data is selected from one or more items of medical complaint data, one or more items of symptom data, one or more items of diagnosis data, or combinations of these.

17. The apparatus of claim 14, wherein said direct patient identification data is located in a corresponding field of said unassociated patient record.

18. The apparatus of claim 1, wherein said indirect patient identification data is selected from medical complaint data, medical history data, age data, gender data, diagnosis data, symptom data, patient physical description data, patient location data, time of treatment data, direct or indirect identification data for a person accompanying the patient, attending medical personnel data, patient address data, patient telephone number data, patient e-mail address data, patient insurance data, patient clothing data, patient skin marking data, data identifying a person accompanying the patient, or any combination of these.

19. The apparatus of claim 1, further comprising a transmitter for presenting said display to a location separated from said data processor.

20. The apparatus of claim 1, further comprising a transmitter for presenting the selection made at said choice input to a location remote from said choice input.

21. The apparatus of claim 1, wherein said display and said choice input are integrated in a portable electronic data processor.

22. The apparatus of claim 1, wherein said display displays plural items of said direct patient identification data.

23. The apparatus of claim 1, wherein said data processor is programmed to present on said display, in association with data identifying the patient, items of said patient identification data relied on to determine the identity of the patient.

24. The apparatus of claim 23, wherein said data processor is programmed to present on said display, in association with said patient identification data relied on to determine the identity of the patient, information about the number of patients identified in said database that present corresponding data.

25. The apparatus of claim 24, wherein said information about the number of patients identified in said database that present corresponding data is a direct statement of the number of such patients having records in said database.

26. The apparatus of claim 24, wherein said information about the number of patients identified in said database that present corresponding data is a statement of the proportion of such patients that present corresponding data in said database.

27. The apparatus of claim 1, wherein said choice input is a computer pointing device associated with said display, said pointing device comprising a selection switch.

28. The apparatus of claim 27, wherein said data processor is programmed to accept a single click of said selection switch, while said pointing device is positioned in proximity to a displayed patient identity, as agreement that the selected patient identity is that of the patient identified in said unassociated record.

29. The apparatus of claim 1, further comprising programming in said data processor to merge said unassociated patient record with the record of the same patient in said database after the unassociated patient record has been associated with said patient.

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.

31. The apparatus of claim 30, wherein said apparatus further comprises a writing instrument for marking on a paper record.

32. A method for associating an unassociated patient record with the corresponding patient, comprising:

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.

33. The method of claim 32, further comprising capturing said unassociated patient record.

34. The method of claim 33, wherein said capturing step is carried out by capturing a series of images from an adjacent position-encoded surface representing the path of movement of a digital encoder in proximity to the position-encoded surface.

35. The method of claim 34, further comprising marking the position-encoded surface as said digital encoder is moved in proximity to said position-encoded surface.

36. The method of claim 34, further comprising associating with said unassociated patient record the location where a patient data input was used to input at least a portion of said unassociated patient record.

37. The method of claim 34, further comprising associating with said unassociated patient record the time when a patient data input was used to input at least a portion of said unassociated patient record.

38. The method of claim 32, further comprising prioritizing the members of said set of one or more known patients presented by said display according to the calculated probability that each said member of said set should be associated with said unassociated patient record.

39. The method of claim 38, further comprising displaying, in connection with at least one member of said set of known patients presented by said display, the calculated probability that the connected member of said set should be associated with said unassociated patient record.

40. The method of claim 32, further comprising extracting optical character data from writing in said unassociated patient record.

41. The method of claim 32, further comprising extracting data from handwriting in said unassociated patient record.

42. The method of claim 41, wherein said data indicates the identity of the writer of said unassociated patient record.

43. The method of claim 32, wherein said direct patient identification data is selected from a first name, a surname, a middle name, a nickname, a pseudonym, a name suffix, a patient number, a social security number, a photograph, a signature, a fingerprint, body scan data, a cell phone number, patient wristband data, or combinations of these.

44. The method of claim 32, wherein said indirect patient identification data is selected from medical complaint data, medical history data, age data, gender data, identifying personal characteristic data, diagnosis data, symptom data, patient physical description data, patient location data, time of treatment data, direct or indirect identification data for a person accompanying the patient, attending medical personnel data, patient address data, patient telephone number data, patient e-mail address data, patient insurance data, patient clothing data, patient skin marking data, data identifying a person accompanying the patient, or combinations of these.

45. The method of claim 32, further comprising presenting said display to a location separated from said data processor.

46. The method of claim 32, further comprising presenting said choice input from a remote location to said data processor.

47. The method of claim 32, further comprising displaying on said display plural items of said direct patient identification data.

48. The method of claim 32, further comprising presenting on said display, in connection with data identifying the patient, items of said patient identification data relied on to associate the patient with the unassociated patient record.

49. The method of claim 48, further comprising presenting on said display, in connection with said patient identification data relied on to determine the identity of the patient, information about the number of patients identified in said database that present corresponding data.

50. The method of claim 49, wherein said information about the number of patients identified in said database that present corresponding data is a direct statement of the number of such patients having records in said database.

51. The method of claim 49, wherein said information about the number of patients identified in said database that present corresponding data is a statement of the proportion of such patients having records in said database.

52. The method of claim 32, further comprising accepting a single click of said selection switch, while said pointing device is positioned in proximity to a displayed patient identity, as agreement that the selected patient identity is that of the patient identified in said unassociated record.

53. The method of claim 32, further comprising merging said unassociated patient record with the record of the same patient in said database after the unassociated patient record has been associated with said patient.

54. Apparatus for providing customized patient discharge instructions, comprising:

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.

55. The apparatus of claim 54, wherein said information in said electronic patient record respecting a post-discharge disability is related to patient-specific discharge instructions instructing the patient how to change daily activity to live successfully with the disability.

56. The apparatus of claim 54, wherein said information in said electronic patient record is related to patient-specific discharge instructions limiting the patient'"'"'s use of an automobile.

57. The apparatus of claim 56, wherein the information in said electronic patient record related to patient-specific discharge instructions limiting the patient'"'"'s use of an automobile records limitations of eyesight, hearing, coordination, reaction time, depth perception, alertness, or memory.

58. A medical chart template comprising:

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.

59. An electronic medical charting system comprising a data processor programmed to review at least one predetermined recording area of the template of claim 58 after said indication has been made in the charting by exception area, identify any of said predetermined recording areas where no data indicating abnormality has been entered, and make a record that the predetermined category of data not entered as abnormal is normal.

60. The medical charting system of claim 59, wherein the set of predetermined categories of data identified by said data processor is customizable.

61. The medical charting system of claim 60, where plural sets of predetermined categories are defined.

62. The medical charting system of claim 61, where said data processor selects a particular set of predetermined categories in a given instance based on information indicating the identity of the medical professional who entered data on at least one recording area of said template.

63. The medical charting system of claim 61, where said data processor selects a particular set of predetermined categories in a given instance based on information indicating the identity of the medical professional who entered data in the charting by exception recording area.

64. The medical charting system of claim 61, where said data processor selects a particular set of predetermined categories in a given instance based on the entry made in the charting by exception recording area selecting said particular set of predetermined categories.

65. The medical chart template of claim 58, comprising a plurality of said charting by exception recording areas, respectively associated with different sets of at least one predetermined category of data on the template to be entered as normal unless an entry has been recorded in the corresponding recording area.

66. The medical chart template of claim 58, where said charting by exception recording area comprises a position-encoded surface.

67. A method of recording medical information on the electronic medical record for a patient, comprising:

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.

68. The method of claim 67, wherein said recording areas are areas of a position-encoded surface.

69. The method of claim 68, wherein said entering steps are carried out by marking said position-encoded surface with a marking instrument.

70. The method of claim 69, wherein said marking instrument further comprises a data capture device for determining what marks have been made in said recording areas and transmitting data reflecting said marks to an electronic medical record system.