Medical records, documentation, tracking and order entry system

• US 5,823,948 A
• Filed: 07/08/1996
• Issued: 10/20/1998
• Est. Priority Date: 07/08/1996
• Status: Expired due to Term

• Current Assignee: RLIS Incorporated
• Original Assignee: RLIS Incorporated
• Inventors: Ross, Jr., James E., Lynch, William J.
• Primary Examiner(s): Kamm, William E.
• Assistant Examiner(s): EVANISKO, GEORGE ROBERT
• Application Number:
  US08/676,458
• Time in Patent Office: 834 Days
• Field of Search: 128/630, 128/906, 128/920, 128/924, 395/202, 395/203, 395/924, 600/300, 705/2, 705/3
• US Class Current: 600/300
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

The new system provides: automatic incorporation of dictated text; medical records summary generation in medical English text; parsing dictation to data; prephrased text; automatic generation of medical record as consequence of data entry; automatic notation of allergies, significant medical conditions and pregnancy; pregnancy linking, automatically; security card--close on pull; multi-look grease board; outstanding orders listing for all patients in the department; department layout; room selection excludes occupied rooms; nurses notes to text; nurses notes from physician orders to nurses; lab request screen shows all previously ordered labs; therapeutics; ACLS recording; lacerations; doctor specific prescriptions and medication orders; review of systems; coding level alerts; differential diagnosis--filter to sex and age; diagnosis--fractures to text; doctor interval reexamination; patient instructions predicated on what was done; patient instruction video on demand; patient informed consent video on demand; video teleconferencing; electronic signatures; automatic backup and incremental backup with system on-line; critical management reports; and automatic research data extraction.

Claims

1. A medical records, documentation, tracking and order entry system, comprising at least one fault tolerant file server having at least one fault tolerant backup server, wherein the at least one file server has either standard hard drives or redundant array of independent drives, a software vendor, at least one communications server linked to the at least one file server for receiving incoming transcription and for remote reception of software, maintenance and system updates from the software vendor, a network having a hub and being connected to the file server, peripheral terminals connected to the network in a star configuration with the hub, the peripheral terminals having individual central processing units (CPUs), the CPUs having hard disks, touch screens, monitor, keyboards and mouses connected to the CPUs;

software provided in the at least one communication server, in the at least one file server, and in the peripheral CPUs for receiving patient data in the peripheral CPUs via the touch screens, mouses, and keyboards and for storing the patient data in the peripheral CPUs and the at least one file server; and

a distributed dictation system having inputs adjacent the CPUs, a transcription system for receiving and converting dictation from the inputs into transcribed dictations and the transcription system being connected to the at least one communication server for transmitting the transcribed dictations to the at least one communications server and an electronic storage bin connected to the at least one communication server for placing the transcribed dictations in the electronic storage bin and for transferring the transcribed dictations to the at least one file server, the electronic storage bin storing the transcribed dictations as text associated with the patient data for particular patients, printers connected to the network for printing reports on individual patients and system management reports of system operations, doctor related activities, nursing related activities and patient statistics.

2. A method of patient record documentation, tracking and order entry, comprising providing software in file servers, providing software from the file servers through a network hub and network to multiple peripheral CPUs, inputting data on data entry screens on monitors connected to the CPUs, the inputting comprising entering patient data in the multiple CPUs by touch screens, mouses and keyboards in response to the data entry screens on monitors connected to the CPUs, transferring the patient data from the CPUs to the file servers, making a record for individual patients, dictating portions of the record that are unique to particular patients, transmitting the dictation over lines to a transcription center, transcribing the dictation and transmitting the dictation transcriptions to at least one communication server, feeding the dictation transcriptions to the file servers as text, storing the text with the patient data on particular patients in the file servers, storing word and sentence generation and coordination software in the peripheral CPUs, generating text sentences in medical English text from patient data, displaying on the monitors connected to the peripheral CPUs the text sentences in medical English text combined with the text from the dictation transcriptions assembled as text summaries, and providing the text summaries from the peripheral CPUs to printers via the network for generation of printed patient textual reports.

3. The method of claim 2, further comprising installing utility software in the peripheral CPUs and generating management reports in the peripheral CPUs by calling the patient data over the network from the file servers and compiling the patient data as text and directing the compiled data to the printer.

4. The method of claim 2, further comprising producing nurses'"'"' notes data by entering the patient data with touch screens, mouses and keyboards, transferring the nurses'"'"' notes data from the peripheral CPUs to the file servers, storing the nurses'"'"' notes data in the file servers, transmitting the nurses'"'"' notes data to the peripheral CPUs, recompiling the nurses'"'"' notes data into nurses'"'"' notes text in the CPUs, displaying the nurses'"'"' notes text on peripheral CPU monitor screens, and printing the nurses'"'"' notes text on the printer.

5. The method of claim 2, further comprising storing prephrased text examples in the peripheral CPUs, and preliminarily inputting prephrased personalized text by individual physicians and nurses, and compiling the personalized text with the patient data for producing medical English text summaries and reports.

6. The method of claim 2, further comprising storing the text summaries in the peripheral CPUs, generating nurses'"'"' orders by entering physician orders to nurses with touch screens, mouses and keyboards at the peripheral CPUs, transmitting the physician orders as physician orders data to the file servers, storing physician orders data with the patient data in the file servers, providing the physician orders data with the patient data from the file servers to the peripheral CPUs, compiling the physicians'"'"' orders data, patient data and the stored text summaries, and displaying the physician orders data as textual nurses'"'"' orders on the displays, displaying all outstanding nurses'"'"' orders on the displays on request, displaying all nurses'"'"' orders specific to a patient on the display, entering executions of the nurses'"'"' orders on the display and automatically changing the executed nurses'"'"' orders to nurses'"'"' textual notes for display and printing in summaries.