Computerized method and system for coding-based navigation

• US 20060106795A1
• Filed: 10/29/2004
• Published: 05/18/2006
• Est. Priority Date: 10/29/2004
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Compton, David L., Eaton, James D. Jr., Matarrese, Paula S.
• Granted Patent: US 8,082,280 B2
• Time in Patent Office: Days
• US Class Current: 1/1
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

Computerized methods and systems for professional evaluation and management coding of a patient visit based upon documentation are provided. Such methods and systems increase efficiency and enhance the quality of clinician documentation by permitting automatic coding as a byproduct of documentation and eliminating the necessity for an after-the-fact check of the patient'"'"'s chart to ensure appropriate documentation. Computerized methods and systems for navigating to a portion of an electronic record, e.g., an electronic medical record, based upon professional evaluation and management coding are also provided, as is the automatic insertion of document content where necessary.

Claims

1. A method in a computing system environment for navigating to a portion of an electronic record based upon coding, the method comprising:

displaying a plurality of elements that are capable of being documented for coding;

receiving user input indicative of one of the plurality of elements; and

if content is present in the electronic record that is associated with the one of the plurality of elements, displaying the associated content.

2. The method of claim 1, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, displaying an indication that no associated content is present.

3. The method of claim 1, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, displaying a user-selectable option to insert content into the electronic record.

4. The method of claim 3, further comprising:

receiving user input indicating content is to be inserted into the electronic record; and

directing the user to the portion of an electronic record associated with the one of the plurality of elements so that content may be inserted.

5. The method of claim 4, further comprising inserting content into the portion of the electronic record associated with the one of the plurality of elements.

6. The method of claim 5, wherein the content inserted into the portion of the electronic record associated with the one of the plurality of elements includes a portion which is at least partially pre-established.

7. The method of claim 6, further comprising receiving user input indicative of personalization of the portion of the content which is at least partially pre-established.

8. A computer system for navigating to a portion of an electronic record based upon coding, the computer system comprising:

a first display module for displaying a plurality of elements that are capable of being documented for coding;

a first receiving module for receiving user input indicative of one of the plurality of elements; and

if content is present in the electronic record that is associated with the one of the plurality of elements, a second display module for displaying the associated content.

9. The computer system of claim 8, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, the computer system further comprises a third display module for displaying an indication that no associated content is present.

10. The computer system of claim 8, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, a fourth display module for displaying a user-selectable option to insert content into the electronic record.

11. The computer system of claim 10, further comprising:

a second receiving module for receiving user input indicating content is to be inserted into the electronic record; and

a directing module for directing the user to a portion of the electronic record associated with the one of the plurality of elements so that content may be inserted.

12. The computer system of claim 11, further comprising an insertion module for inserting content into the portion of the electronic record associated with the one of the plurality of elements.

13. The computer system of claim 12, wherein the content inserted into the portion of the electronic record associated with the one of the plurality of elements includes a portion which is at least partially pre-established.

14. The computer system of claim 13, further comprising a third receiving module for receiving user input indicative of personalization of the portion of the content which is at least partially pre-established.

15. A computer-readable medium having computer-executable instructions for performing a method in a computing system environment for navigating to a portion of an electronic record based upon coding, the method comprising:

displaying a plurality of elements that are capable of being documented for coding a patient visit;

receiving user input indicative of one of the plurality of elements; and

if content is present in the electronic record that is associated with the one of the plurality of elements, displaying the associated content.

16. The computer-readable medium of claim 15, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, the method further comprises displaying an indication that no associated content is present.

17. The computer-readable medium of claim 15, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, the method further comprises displaying a user-selectable option to insert content into the electronic record.

18. The computer-readable medium of claim 17, wherein the method further comprises:

receiving user input indicating content is to be inserted into the electronic record; and

directing the user to the portion of the electronic record associated with the one of the plurality of elements so that content may be inserted.

19. The computer-readable medium of claim 18, wherein the method further comprises inserting content into the portion of the electronic record associated with the one of the plurality of elements.

20. The computer-readable medium of claim 19, wherein the content inserted into the portion of the electronic record associated with the one of the plurality of elements includes a portion which is at least partially pre-established.

21. The computer-readable medium of claim 20, wherein the method further comprises receiving user input indicative of personalization of the portion of the content which is at least partially pre-established.

22. A user interface embodied on at least one computer-readable medium, the user interface for navigating to portions of an electronic record based upon coding, the user interface comprising a coding summary display area configured to display a typical coding level based upon a reason for a patient visit and a current coding level based upon a quantity of documented elements.

23. The user interface of claim 22, further comprising a documentation summary display area configured to display one or more of the current coding level, the quantity of documented elements, a quantity of elements to be documented to achieve the typical coding level, and a quantity of documents remaining to be documented to achieve the typical coding level.

24. The user interface of claim 23, further comprising a coding element display area configured to display a plurality of selectable element links each indicative of an element that is capable of being documented for coding.

25. The user interface of claim 24, wherein the quantity of documented elements is a selectable link, and whereby following the selectable link allows the user to navigate to the coding element display area of the user interface.

26. The user interface of claim 25, whereby following one of the selectable element links of the coding element display area allows the user to navigate to content in the electronic record that is associated with the element indicated by the one of the selectable element links.

27. A computer system for navigating to a portion of an electronic record based upon coding, the computer system comprising:

means for displaying a plurality of elements that are capable of being documented for coding;

means for receiving user input indicative of one of the plurality of elements; and

if content is present in the electronic record that is associated with the one of the plurality of elements, means for displaying the associated content.

28. The computer system of claim 27, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, means for displaying an indication that no associated content is present.

29. The computer system of claim 27, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, means for displaying a user-selectable option to insert content into the electronic record.

30. The computer system of claim 29, further comprising:

means for receiving user input indicating content is to be inserted into the electronic record; and

means for directing the user to the portion of an electronic record associated with the one of the plurality of elements so that content may be inserted.

31. The computer system of claim 30, further comprising means for inserting content into the portion of the electronic record associated with the one of the plurality of elements.

32. The computer system of claim 31, wherein the content inserted into the portion of the electronic record associated with the one of the plurality of elements includes a portion which is at least partially pre-established.

33. The computer system of claim 32, further comprising means for receiving user input indicative of personalization of the portion of the content which is at least partially pre-established.