Clinical documentation system for use by multiple caregivers
First Claim
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1. A system for documenting patient information from multiple caregivers comprising:
- a health record system including a plurality of data elements, the data elements including patient note data acquired from multiple caregivers, the patient note data including at least a first patient note and a second patient note related to the care of a given patient; and
a first interface and a second interface coupled to the health record system each including a graphic display, the first interface and second interface operable to retrieve, based upon information received from a first and second user, patient note data associated with a specified patient, and to graphically depict the patient note data in list form and text form within the graphic displays, each of the first and second interfaces further including an editor operable with the interface to facilitate editing of the patient notes within the graphic display;
wherein the first interface is adapted to lock the first patient note when the first user is editing the first patient note such that the second interface maintains view access to the patient notes but is denied write access to the first patient note while the first user is editing the first patient note, and wherein the second interface is adapted to simultaneously lock the second patient note when the second user is editing the second patient note such that the first interface maintains simultaneous view access to the patient notes but is denied write access to the second patient note while the second user is editing the second patient note; and
wherein each interface further includes a role-based security scheme that limits at least one of the first and second user'"'"'s viewing and editing access to the patient note data associated with the specified patient to only limited types of information based on a role of the user.
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Abstract
A computer-based system for recording, storing, and accessing clinical documentation in an acute care setting is provided. In an embodiment of the invention, a single electronic database or repository for storing clinical patient notes, provides multiple points of read/write access via a user interface operating on one or more client computers that are in real-time communication with the repository.
191 Citations
23 Claims
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1. A system for documenting patient information from multiple caregivers comprising:
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a health record system including a plurality of data elements, the data elements including patient note data acquired from multiple caregivers, the patient note data including at least a first patient note and a second patient note related to the care of a given patient; and a first interface and a second interface coupled to the health record system each including a graphic display, the first interface and second interface operable to retrieve, based upon information received from a first and second user, patient note data associated with a specified patient, and to graphically depict the patient note data in list form and text form within the graphic displays, each of the first and second interfaces further including an editor operable with the interface to facilitate editing of the patient notes within the graphic display; wherein the first interface is adapted to lock the first patient note when the first user is editing the first patient note such that the second interface maintains view access to the patient notes but is denied write access to the first patient note while the first user is editing the first patient note, and wherein the second interface is adapted to simultaneously lock the second patient note when the second user is editing the second patient note such that the first interface maintains simultaneous view access to the patient notes but is denied write access to the second patient note while the second user is editing the second patient note; and wherein each interface further includes a role-based security scheme that limits at least one of the first and second user'"'"'s viewing and editing access to the patient note data associated with the specified patient to only limited types of information based on a role of the user. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15)
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16. A method of documenting patient note data within a health record system, the health record system including data structures for storing the patient note data, provider data and user data, the method comprising the steps of:
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collecting first and second patient note data from a plurality of caregivers and storing the patient note data in at least one of the data structures; providing a first interface and a second interface coupled to the health record system, each interface including a graphic display and an editor operable with the interface to facilitate editing of the patient note data within the graphic display, and for a patient, listing the patient note data in a first portion of each graphic display and text linked with the patient note data in a second portion of each graphic display; locking the first patient note data when a first user of the first interface is editing the first patient note data such that a second user of the second interface maintains view access to the patient note data but is denied write access to the first patient note data while the first user is editing the first patient note data, and locking the second patient note data when the second user of the second interface is editing the second patient note data such that the first user maintains simultaneous view access to the patient note data but is denied write access to the second patient note data while the second user is editing the second patient note data; and limiting at least one of the first and second user'"'"'s viewing and editing access to the patient note data associated with the specified patient only to limited types of information based on a role of the user. - View Dependent Claims (17, 18, 19, 20, 21, 22, 23)
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Specification