Medical documentation and assessment apparatus

• US 5,636,873 A
• Filed: 11/28/1994
• Issued: 06/10/1997
• Est. Priority Date: 11/28/1994
• Status: Expired due to Fees

• Current Assignee: Kristi L. Sonsteby
• Original Assignee: Kristi L. Sonsteby
• Inventors: Sonsteby, Kristi L.
• Primary Examiner(s): HAN, FRANCES CHIN
• Application Number:
  US08/348,846
• Time in Patent Office: 925 Days
• Field of Search: 434/262, 434/178, 434/433, 40/359, 40/360, 283/81, 283/101, 283/900, 283/117, 128/630, 128/771
• US Class Current: 283/81
• CPC Class Codes: B42D 15/00 Printed matter of special format or style not otherwise provided for
• CPC Class Codes: G09F 3/10 by an adhesive layer
• CPC Class Codes: Y10S 283/90 Medical record

Abstract

A documentation system that allows adequate control of documentation in addition to an assessment of skills of the professionals involved includes a plurality of notepads, each notepad dedicated to a particular disease process or body system. Each of the notepads has disposed therein a plurality of adhesive-backed labels, each label providing a checklist of assessment steps or an anatomical diagram of a particular body system. The labels are operable to be removed and temporarily placed on the chart of the patient during an acute episode, incident, or accident, or may be permanently placed in the patient'"'"'s chart to describe adequately the patient'"'"'s condition. In addition, the anatomy labels are operable to be removed from the notepad and given to the patient to assist the patient in understanding his/her disease process or medical condition. Also included is an optional Charting Reminder Tool form, operable to be placed in the patient'"'"'s chart for attachment of the labels.

Claims

1. A documentation apparatus for use in association with a patient'"'"'s medical chart, comprising:

a charting reminder sheet of paper, said sheet of paper containing a plurality of bordered blank spaces, a plurality of blank lines for date and signature, and a checklist explaining the need for follow-up;

a plurality of adhesive-backed labels, said labels containing predetermined assessment and documentation information associated with a separate and particular medical occurrence or disease process, and

each said particular information label contained in an adhesive-bound notepad containing a plurality of identical medical information labels, and

said medical information comprising either;

a predetermined anatomical diagram with associated medical reference terminology defined in text, or

a checklist including predetermined documentation guidelines defined in text.

2. The documentation apparatus of claim 1 wherein each said label dimensioned to fit in the bordered blank space on the charting reminder sheet of paper.

3. The documentation apparatus of claim 1 wherein each said label contains a predetermined title associated with the checklist or anatomical diagram thereon.

4. The documentation apparatus of claim 1 wherein each of said checklist labels contains a plurality of predetermined documentation steps, each said textural description preceded by an indicator marker.

5. A temporary method for documenting care in a medical environment, and in association with a patient'"'"'s medical chart, comprising:

defining a plurality of medical occurrences or disease processes,

selecting a medical occurrence or disease process,

selecting an associated body system,

providing a plurality of charting reminder sheets of paper, each dimensional to fit in a patient'"'"'s medical chart,

providing on each charting reminder sheet a plurality of bordered blank spaces,

providing a plurality of adhesive-backed labels in a notepad format, each label dimensioned to fit in the bordered blank spaces on the charting reminder sheet of paper,

providing a plurality of checklist labels containing documentation steps in text relating to the selected medical occurrence or disease process,

providing a plurality of anatomical labels, each containing an anatomical diagram of a particular body system and salient medical terminology for the associated medical occurrence or disease process,

providing on each of the said labels a title of the associated medical occurrence, disease process, or body system, and

removing the label from the notepad when follow-up for an acute episode, incident, or accident is presented, and

attaching the removed label to the charting reminder sheet of paper, and

inserting the charting reminder sheet of paper into the patient'"'"'s medical chart for the duration of the follow-up procedure, and

removing the charting reminder sheet of paper, with attached labels, when the follow-up procedure is completed.

6. A permanent method for documentation verification in a medical environment, and in association with a patient'"'"'s chart, comprising:

defining a plurality of medical occurrences or disease processes,

selecting a medical occurrence or disease process,

selecting an associated body system,

providing a plurality of adhesive-backed labels in a notepad format, each label dimensioned to fit in the physician'"'"'s progress notes or the nurse'"'"'s notes, and

providing a plurality of checklist labels containing documentation steps in text relating to the selected medical occurrence or disease process,

providing a plurality of anatomical labels, each containing an anatomical diagram of a particular body system and salient medical terminology for the associated medical occurrence or disease process,

providing on each of the said labels a title of the associated medical occurrence, disease process, or body system,

removing the label from the notepad when the need for documentation is presented

attaching the removed label to the physician'"'"'s progress notes or nurse'"'"'s notes

retaining the label in the chart as a permanent record of care.

7. A method of patient teaching in a medical environment, comprising:

defining a plurality of medical occurrences or disease processes,

selecting a medical occurrence or disease process,

selecting an associated body system,

providing a plurality of anatomical labels, each containing an anatomical diagram of a particular body system and salient medical terminology for the associated medical occurrence or disease process,

providing on each of the said labels a title of the associated medical occurrence, disease process, or body system, and

removing the label from the notepad when the need to educate a patient arises, and

giving the label to the patient after an explanation of his/her condition.