Method and apparatus for performing patient documentation
First Claim
1. A documentation system for a hospital patient comprising:
- means for generating an initial health care plan for the patient, the care plan having a plurality of entries, including entries identifying patient'"'"'s health care problems, expected outcomes for such problems, and interventions to achieve such outcomes;
means for periodically entering progress notes on the patient into the system, said progress notes including, as appropriate, changes for one or more entries of the care plan; and
means responsive to a change being entered for an entry in a progress note for automatically updating the care plan for the patient by making a corresponding change in the corresponding care plan entry.
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Accused Products
Abstract
This invention provides a hospital patient documentation method and apparatus which is used to generate an initial patient health plan which identifies the patient'"'"'s health problems, the causes of the problems, expected outcomes, and interventions to achieve such outcomes. The system also provides for the periodic entry of progress notes on the patient, with the system automatically updating the care plan for the patient in response to the progress notes. The initial care plan and all updates are stored so that a audit trail is maintained and the user may obtain either a current patient health plan or a historical patient health plan on demand. The system is menu driven to facilitate uniformity and menu items are coded to facilitate subsequent retrieval and processing. Outcomes are displayed with outcome due dates and progress note generation may be inhibited if, on an outcome due date, the outcome has not been achieved or the due date updated.
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Citations
65 Claims
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1. A documentation system for a hospital patient comprising:
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means for generating an initial health care plan for the patient, the care plan having a plurality of entries, including entries identifying patient'"'"'s health care problems, expected outcomes for such problems, and interventions to achieve such outcomes; means for periodically entering progress notes on the patient into the system, said progress notes including, as appropriate, changes for one or more entries of the care plan; and means responsive to a change being entered for an entry in a progress note for automatically updating the care plan for the patient by making a corresponding change in the corresponding care plan entry. - 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, 30, 31, 32)
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33. A method for performing hospital documentation comprising the steps of:
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generating an initial health care plan for a patient, the care plan having a plurality of entries including entries identifying patient medical problems, expected outcomes for such problems and medical interventions to achieve the outcomes; periodically entering progress notes on the patient, said progress notes including, as appropriate, changes for one or more entries of the care plan; and automatically updating the care plan for the patient in response to a change being entered for an entry in a progress note by making a corresponding change in the corresponding care plan entry. - View Dependent Claims (34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64)
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65. A documentation system for a hospital patient comprising:
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means for generating an initial health care plan for the patient, the care plan identifying patient health care problems, expected outcomes for such problems, due dates for each expected outcome and interventions to achieve such outcomes; means for periodically entering progress notes on the patient into the system; and means responsive to an outcome not being achieved on the due date for inhibiting the entering of the progress note until an appropriate change is made in the due date or outcome.
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Specification