Clinical documentation system for use by multiple caregivers

• US 7,251,610 B2
• Filed: 09/10/2001
• Issued: 07/31/2007
• Est. Priority Date: 09/20/2000
• Status: Active Grant

• Current Assignee: Epic Systems Corporation
• Original Assignee: Epic Systems Corporation
• Inventors: Alban, Christopher, Seow, Khiang
• Primary Examiner(s): Rudy; Andrew Joseph
• Assistant Examiner(s): Frenel; Vanel
• Application Number:
  US09/950,185
• Publication Number:
  US 20020062229A1
• Time in Patent Office: 2,150 Days
• Field of Search: 705 2- 3, 704/270
• US Class Current: 705/3
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 80/00 ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring

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.

Claims

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.

2. The system of claim 1, wherein the editor is operable with the interface to facilitate creation of patient note data.

3. The system of claim 1, wherein the editor is operable independent of the depiction of the patient note data within the graphic display.

4. The system of claim 1, wherein the plurality of caregivers are associated with a plurality of medical services.

5. The system of claim 1, wherein the plurality of caregivers are associated with a plurality of related medical services.

6. The system of claim 1, wherein the interface further comprises a filter for selecting particular patient note data for depiction within the graphic display.

7. The system of claim 6, further comprising filter criteria associated with the filter, the filter criteria comprising at least one of:

author, author type and time.

8. The system of claim 1, wherein the patient note data is linked by time stamp data.

9. The system of claim 8, wherein the patient note data is graphically depicted within the graphic display according to the time stamp data.

10. The system of claim 1, wherein the interface further comprises a searcher operable with the interface to facilitate searching of the patient note data for depiction within the graphic display.

11. The system of claim 10, wherein the patient note data includes tag data, and wherein the searcher is operable on the tag data.

12. The system of claim 1, wherein the patient note data includes cosign data.

13. The system of claim 12, wherein the cosign data comprises a cosign from at least one caregiver.

14. The system of claim 12, wherein the cosign data comprises cosign requirement data, the cosign requirement data specifying a number of required cosigns.

15. The system of claim 1, wherein the patient note data comprise soft-deleted data.

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:

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.

17. The method of claim 16, further comprising filtering the patient note data to provide filtered patient note data and listing the filtered patient note data in the first portion of the graphic display and text linked with the filtered note data in the second portion.

18. The method of claim 16, wherein the step of collecting patient note data from a plurality of caregivers comprises collecting patient note data from a plurality of unrelated caregivers.

19. The method of claim 16, wherein the step of collecting patient note data from a plurality of caregivers comprises collecting patient note data from a plurality of related caregivers.

20. The method of claim 16, wherein the patient note data comprises time stamp data, and wherein the step of listing the patient note data comprises listing the patient note data according to the time stamp data.

21. The system of claim 16, wherein the patient note data includes tag data, and wherein the method further comprises the step of assembling a report of the patient note data based upon the tag data.

22. The system of claim 16, wherein the patient note data includes cosign data, and wherein the method further comprises the step of cosigning the patient note data in accordance with the cosign data.

23. The system of claim 16, wherein the patient note data comprises soft delete data, and wherein the method further comprises storing the patient note data in accordance with the soft delete data.