SURGICAL OPERATIVE NOTES

• US 20140074511A1
• Filed: 11/12/2013
• Published: 03/13/2014
• Est. Priority Date: 01/04/2012
• Status: Active Grant

• Current Assignee: Universal Research Solutions, LLC
• Original Assignee: Universal Research Solutions, LLC
• Inventors: Hussam, Ali Adel, Bleigh, Nathan
• Granted Patent: US 10,607,725 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G09B 23/28 for medicine
• CPC Class Codes: G16H 10/20 for electronic clinical trials or questionnaires
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A computer-implemented method comprising: retrieving a surgical center template for a surgical procedure that is performed by a surgical center; retrieving medical records pertaining to the patient; automatically pre-populating a portion of the template based on contents of the retrieved medical data records; transmitting, to a device used by a physician, the pre-populated template for presentation to the physician; receiving data pertaining to the surgical procedure, wherein the received data comprises at least one of data entered into a predefined data field of the plurality of predefined data fields and data indicative of a selection of a selectable field in the plurality of selectable fields; populating one or more other portions of the template with the received data pertaining to the surgical procedure; and generating, based on the populated template, a surgical operative note for the surgical procedure.

Claims

1. A computer-implemented method comprising:

retrieving a surgical center template for a surgical procedure that is performed by a surgical center, wherein the surgical center template comprises one or more of (i) a plurality of predefined data fields for entry of medical data, and (ii) a plurality of selectable fields for selection of an attribute of a patient on whom the surgical procedure is performed or an attribute of the surgical procedure;

retrieving medical records pertaining to the patient;

automatically pre-populating a portion of the template based on contents of the retrieved medical data records;

transmitting, to a device used by a physician, the pre-populated template for presentation to the physician;

receiving, from the device used by the physician, data pertaining to the surgical procedure, wherein the received data comprises at least one of data entered into a predefined data field of the plurality of predefined data fields and data indicative of a selection of a selectable field in the plurality of selectable fields;

populating one or more other portions of the template with the received data pertaining to the surgical procedure; and

generating, based on the populated template, a surgical operative note for the surgical procedure, with the surgical operative note comprising a summary of the surgical procedure and one or more details of the surgical procedure.

2. The computer-implemented method of claim 1, wherein the surgical operative note comprises one or more details of an implant or a device used during the surgical procedure.

3. The computer-implemented method of claim 1, wherein generating the surgical operative note comprises:

structuring the surgical operative note into a plurality of operative portions, each of the plurality of operative portions related to a stage of a plurality of stages of the surgical procedure.

4. The computer-implemented method of claim 3, wherein the plurality of operative portions comprise a consultation portion, a pre-operative portion, an intra-operative portion, a post-operative portion, and a discharge portion.

5. The computer-implemented method of claim 1, wherein the surgical center template comprises:

pre-operative portion for entry of data pertaining to a time period prior to the surgical procedure;

an intra-operative portion for entry of data pertaining to performance of the surgical procedure;

a post-operative portion for entry of data pertaining to an outcome of the surgical procedure or data related to recovery from the surgical procedure; and

a discharge portion for entry of data pertaining to discharge from the surgical center.

6. The computer-implemented method of claim 1, wherein the surgical center template comprises a visualization related to the surgical procedure, and the method further comprises:

labeling one or more portions of the visualization based on the medical information included in the medical records pertaining to the patient.

7. The computer-implemented method of claim 6, wherein receiving, from the device used by the physician, data pertaining to the surgical procedure comprises:

receiving data indicative of an annotation of a portion of the visualization.

8. The computer-implemented method of claim 1, wherein receiving, from the device used by the physician, data pertaining to the surgical procedure comprises:

receiving data indicative of a barcode associated with an implantable device that is used in the surgical procedure; and

the method further comprises;

retrieving data associated with the barcode from a data repository;

updating a portion of the surgical center template with the retrieved data that is associated with the bar code; and

transmitting, to the device used by the physician, the retrieved data for presentation with the surgical center template.

9. The computer-implemented method of claim 1, further comprising:

determining, based on the received data pertaining to the surgical procedure, whether the surgical procedure is in compliance with national medical standards.

10. The computer-implemented method of claim 1, further comprising:

determining that required data pertaining to the surgical procedure has not been received from the device used by the physician; and

transmitting, to the device used by the physician for presentation to the physician, a notification that the required data has not been received.

11. One or more machine-readable hardware storage devices storing instructions that are executable by one or more processing devices to perform operations comprising:

retrieving a surgical center template for a surgical procedure that is performed by a surgical center, wherein the surgical center template comprises one or more of (i) a plurality of predefined data fields for entry of medical data, and (ii) a plurality of selectable fields for selection of an attribute of a patient on whom the surgical procedure is performed or an attribute of the surgical procedure;

retrieving medical records pertaining to the patient;

automatically pre-populating a portion of the template based on contents of the retrieved medical data records;

transmitting, to a device used by a physician, the pre-populated template for presentation to the physician;

receiving, from the device used by the physician, data pertaining to the surgical procedure, wherein the received data comprises at least one of data entered into a predefined data field of the plurality of predefined data fields and data indicative of a selection of a selectable field in the plurality of selectable fields;

populating one or more other portions of the template with the received data pertaining to the surgical procedure; and

generating, based on the populated template, a surgical operative note for the surgical procedure, with the surgical operative note comprising a summary of the surgical procedure and one or more details of the surgical procedure.

12. The one or more machine-readable hardware storage devices of claim 11, wherein the surgical operative note comprises one or more details of an implant or a device used during the surgical procedure.

13. The one or more machine-readable hardware storage devices of claim 11, wherein generating the surgical operative note comprises:

structuring the surgical operative note into a plurality of operative portions, each of the plurality of operative portions related to a stage of a plurality of stages of the surgical procedure.

14. The one or more machine-readable hardware storage devices of claim 13, wherein the plurality of operative portions comprise a consultation portion, a pre-operative portion, an intra-operative portion, a post-operative portion, and a discharge portion.

15. The one or more machine-readable hardware storage devices of claim 11, wherein the surgical center template comprises:

pre-operative portion for entry of data pertaining to a time period prior to the surgical procedure;

an intra-operative portion for entry of data pertaining to performance of the surgical procedure;

a post-operative portion for entry of data pertaining to an outcome of the surgical procedure or data related to recovery from the surgical procedure; and

a discharge portion for entry of data pertaining to discharge from the surgical center.

16. An electronic system comprising:

one or more process devices; and

one or more machine-readable hardware storage devices storing instructions that are executable by one or more processing devices to perform operations comprising;

retrieving a surgical center template for a surgical procedure that is performed by a surgical center, wherein the surgical center template comprises one or more of (i) a plurality of predefined data fields for entry of medical data, and (ii) a plurality of selectable fields for selection of an attribute of a patient on whom the surgical procedure is performed or an attribute of the surgical procedure;

retrieving medical records pertaining to the patient;

automatically pre-populating a portion of the template based on contents of the retrieved medical data records;

transmitting, to a device used by a physician, the pre-populated template for presentation to the physician;

receiving, from the device used by the physician, data pertaining to the surgical procedure, wherein the received data comprises at least one of data entered into a predefined data field of the plurality of predefined data fields and data indicative of a selection of a selectable field in the plurality of selectable fields;

populating one or more other portions of the template with the received data pertaining to the surgical procedure; and

generating, based on the populated template, a surgical operative note for the surgical procedure, with the surgical operative note comprising a summary of the surgical procedure and one or more details of the surgical procedure.

17. The electronic system of claim 16, wherein the surgical operative note comprises one or more details of an implant or a device used during the surgical procedure.

18. The electronic system of claim 16, wherein generating the surgical operative note comprises:

structuring the surgical operative note into a plurality of operative portions, each of the plurality of operative portions related to a stage of a plurality of stages of the surgical procedure.

19. The electronic system of claim 18, wherein the plurality of operative portions comprise a consultation portion, a pre-operative portion, an intra-operative portion, a post-operative portion, and a discharge portion.

20. The electronic system of claim 16, wherein the surgical center template comprises:

pre-operative portion for entry of data pertaining to a time period prior to the surgical procedure;

an intra-operative portion for entry of data pertaining to performance of the surgical procedure;

a post-operative portion for entry of data pertaining to an outcome of the surgical procedure or data related to recovery from the surgical procedure; and

a discharge portion for entry of data pertaining to discharge from the surgical center.