Medical records, documentation, tracking and order entry system

• US 7,076,436 B1
• Filed: 06/19/1998
• Issued: 07/11/2006
• Est. Priority Date: 07/08/1996
• Status: Expired due to Fees

• Current Assignee: RLIS Incorporated
• Original Assignee: RLIS Incorporated
• Inventors: Ross, Jr., James E., Lynch, William J.
• Primary Examiner(s): Poinvil, Frantzy
• Application Number:
  US09/100,100
• Time in Patent Office: 2,944 Days
• Field of Search: 705/3, 705/2, 705/1, 705/5, 705/6, 705/7, 705/8, 705/9, 705/4, 704/1, 707/500
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/06316 Sequencing of tasks or work
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 70/60 relating to pathologies
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

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 method for rendering a report including medical language from previously stored data, said method comprising:

storing sentences and phrases related to medical data,

inputting patient data at a peripheral data input device,

transferring the patient data from the peripheral data input device to a server communicatively coupled to the peripheral data input device and tabling the patient data at the server,

transferring the tabled patient data from the server to a report rendering component, and

compiling sentences and paragraphs by the report rendering component from the stored sentences and phrases and the patient data, whereby stored medical facts associated with the input patient data are converted into sentence structure.

2. The method of claim 1, further comprising rearranging the medical facts compiled into sentence structure into a medically appropriate order.

3. The method of claim 2, further comprising consolidating, by the report rendering component, automatically generated medical English text with patient-related stored text.

4. The method of claim 3, further comprising inserting, by the report rendering component, headlines and sub headlines within the report.

5. The method of claim 3, further comprising modifying, in accordance with programmed report generation instructions, the font of text within particular portions of the report to use of bold, italic, and larger text sizes to emphasize important medical sections or information.

6. A method for rendering a report including medical language from previously stored data, said method comprising

storing sentences and phrases related to medical data,

inputting patient data via a data input device,

transferring the patient data to a server and tabling the patient data,

transferring the tabled patient data to a report rendering component, and

compiling sentences and paragraphs by the report rendering component from the stored sentences and phrases and the patient data, and thereby converting stored medical patient data, including the input patient data, into medical facts in sentence structure.

7. The method of claim 6, further comprising rearranging the medical facts compiled into sentence structure into a medically appropriate order.

8. The method of claim 7, further comprising consolidating, by the report rendering component, generated medical text with patient-related stored text including dictated transcripts.

9. The method of claim 8, further comprising inserting, by the report rendering component, headlines and sub headlines in the generated medical text where appropriate.

10. The method of claim 9, further comprising modifying, in accordance with programmed report generation instructions, the font of text within particular portions of the report to use bold, italic, and larger text sizes to emphasize important medical sections or information in the generated medical text.

11. A method for computer-aided generation of patient medical documentation assembled from a combination of sources including user supplied text, system supplied pre-phrased text retrieved from a database in accordance with a specified pre-phrased text identifier, and text generated from input medical data facts, said method comprising the steps of:

associating multiple pieces of information regarding a patient with a patient medical information record, the multiple pieces of medical information comprising;

input text of the type generally arising from transcribed dictation,

pre-phrased text retrieved from an electronic data storage apparatus and associated with a pre-phrased text identifier, and

medical data facts,

wherein inputs relating to the multiple pieces of information regarding the patient are received by a medical information input interface providing random access to at least one of a set of medical information fields associated with the patient medical information record;

receiving an identification of a patient medical document type; and

generating, by a computer system under software control, a patient medical document based upon at least a portion of the multiple pieces of information regarding the patient and an information specification corresponding to the patient medical document type identification that specifies the portion of the multiple pieces of information to be included in the patient medical document, said generating step comprising, in any order;

first inserting the input text at locations within the patient medical document in accordance with a text type associated with each distinguished portion of the input text,

second inserting text corresponding to the pre-phrased text retrieved from an electronic data storage apparatus, and

third inserting text generated in accordance with the medical data facts.

12. The method of claim 11 wherein the text generated in accordance with the medical data facts is generated in accordance with a medically logical sequence.

13. The method of claim 11 wherein the step of generating a patient medical document further comprising generating heading text in accordance with the patient medical document type designation.

14. The method of claim 11 wherein the step of generating a patient medical document further comprises arranging the multiple pieces of information regarding the patient in accordance with the medical document type designation.

15. The method of claim 14 wherein the patient medical document is a patient medical report.

16. The method of claim 14 wherein the patient medical document is a triage record.

17. The method of claim 14 wherein the patient medical document comprises nurse notes.

18. The method of claim 11 wherein the text generated in accordance with the medical data facts is medical text.

19. The method of claim 11 further comprising providing an editing tool to modify specified pre-phrased text.

20. The method of claim 11 further comprising providing a set of selectively activated input modules facilitating prompted input of information relating to care for a patient.

21. The method of claim 11 further comprising providing a security mechanism facilitating limiting access to particular users.

22. The method of claim 11 further comprising recording a time at which a particular piece of information is submitted for a patient medical record.

23. The method of claim 22 further comprising recording an identity of a logged on user that supplied a particular piece of information stored in the patient medical information record.

24. A system for computer-aided generation of patient medical documentation assembled from a combination of sources including user supplied text, system supplied pre-phrased text retrieved from a database in accordance with a specified pre-phrased text identifier, and text generated from input medical data facts, said system comprising:

computer executable database software for associating multiple pieces of information regarding a patient with a patient medical information record, the multiple pieces of medical information comprising;

input text of the type generally arising from transcribed dictation,

pre-phrased text retrieved from an electronic data storage apparatus and associated with a pre-phrased text identifier, and

medical data facts,

wherein inputs relating to the multiple pieces of information regarding the patient are received by a medical information input interface providing random access to at least one of a set of medical information fields associated with the patient medical information record; and

computer executable document generation software for receiving an identification of a patient medical document type, and in response generating a patient medical document based upon at least a portion of the multiple pieces of information regarding the patient and an information specification corresponding to the patient medical document type identification that specifies the portion of the multiple pieces of information to be included in the patient medical document, said generating a patient medical document comprising, in any order;

first inserting the input text at locations within the patient medical document in accordance with a text type associated with each distinguished portion of the input text,

second inserting text corresponding to the pre-phrased text retrieved from an electronic data storage apparatus, and

third inserting text generated in accordance with the medical data facts.

25. The system of claim 24 wherein the computer executable document generation software includes software instructions for arranging the multiple pieces of information regarding the patient in accordance with the medical document type designation.

26. The method of claim 25 wherein the patient medical document is a patient medical report.

27. The method of claim 25 wherein the patient medical document is a triage record.

28. The method of claim 25 wherein the patient medical document comprises nurse notes.

29. The method of claim 24 wherein the text generated in accordance with the medical data facts is medical text.

30. The method of claim 24 further comprising an editing software utility facilitating modifying specified pre-phrased text.

31. The method of claim 24 further comprising a set of selectively activated input modules facilitating prompted input of information relating to care for a patient.

32. The system of claim 24 further comprising a security mechanism facilitating limiting access to particular users.

33. The system of claim 32 wherein the security mechanism includes executable software for recording and identity of a logged on user that supplied a particular piece of information stored in the patient medical information record.

34. The system of claim 32 further comprising computer software for recording a time at which a particular piece of information is submitted for a patient medical record.