Utilizing conditional logic in medical documentation

• US 8,103,525 B2
• Filed: 01/09/2009
• Issued: 01/24/2012
• Est. Priority Date: 01/09/2009
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Kelly, Lisa, Gannon, Mary
• Primary Examiner(s): O'Connor, Gerald J.
• Assistant Examiner(s): PAULS, JOHN A
• Application Number:
  US12/351,448
• Publication Number:
  US 20100179818A1
• Time in Patent Office: 1,110 Days
• Field of Search: 705/2, 705/3, 600/437
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/0637 Strategic management or analysis, e.g. setting a goal or target of an organisation; Planning actions based on goals; Analysis or evaluation of effectiveness of goals
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 40/63 for local operation
• CPC Class Codes: G16H 70/20 relating to practices or guidelines

Abstract

Methods, computer storage media, systems and user interfaces that guide a clinician to complete medical documentation. The method, computer storage media, system and user interfaces include presenting a first medical documentation set to indicate a medical aspect for which medical data is to be documented. At least one of the medical documentation elements in the first set is linked to a second medical documentation set. A selection of one of the linked medical documentation elements in the first set is received, and the second medical documentation set is presented. An attribute for at least one of the medical data fields in the first or second set is received, and the attributes received for the first and the second medical documentation sets are aggregated into a medical data group.

Claims

1. One or more computer storage media having computer-executable instructions embodied thereon for performing a method in a clinical computing environment that guides a clinician to complete medical documentation, the method comprising:

presenting a first medical documentation set having a first set of medical documentation elements and a first set of medical data fields to indicate a medical aspect for which medical data is to be documented;

indicating that at least one of the medical documentation elements in the first set is linked to a second medical documentation set having a second set of medical documentation elements and a second set of medical data fields to indicate a medical aspect for which medical data is to be documented;

receiving a selection of at least one of the linked medical documentation elements in the first set;

presenting the second set of medical documentation elements and medical data fields in response to the selection;

receiving an attribute for at least one of the medical data fields in the first or second set;

aggregating the attributes received for the first and the second medical documentation sets into a medical data group; and

presenting the medical data group including result details for any uncharted labels; and

presenting an unchart display area configured to enable a user to remove attributes from the medical data group display area;

wherein the unchart display area displays the attributes including one or more of a medical label name, a date/time, a creator and a status of the medical label and a reason for uncharting and wherein enabling a user to remove attributes comprises selecting an indicator indicating that the attributes is to be uncharted and wherein the reason for uncharting is subsequently displayed in the corresponding medical documentation element.

2. The one or more computer-readable media of claim 1, wherein indicating that at least one of the medical documentation elements in the first set is linked to a second medical documentation set comprises presenting an icon in association with at least one of the medical documentation elements presented in the first set or implementing a distinguishable font to display at least one of the medical documentation elements presented in the first set.

3. The one or more computer-readable media of claim 1, wherein the method further comprises indicating that an attribute is required for at least one of the medical data fields in the first set, the second set, or both sets.

4. The one or more computer-readable media of claim 3, wherein indicating that an attribute is required for at least one of the medical data fields comprises implementing an icon, a font, a color indicator, an audio signal, or combination thereof to distinguish the required medical data field from other medical data fields.

5. The one or more computer-readable media of claim 1, wherein receiving a selection of at least one of the linked medical documentation elements in the first set comprises receiving an attribute for one of the medical data fields in the first set.

6. The one or more computer-readable media of claim 1, wherein receiving a selection of at least one of the linked medical documentation elements in the first set comprises receiving a predetermined attribute that triggers presenting the second set of medical documentation elements.

7. The one or more computer-readable media of claim 1, wherein receiving an attribute for at least one of the medical data fields in the first or second sets comprises displaying a list associated with the medical data fields and receiving a selection from the list.

8. The one or more computer-readable media of claim 1, wherein receiving an attribute for at least one of the medical data fields in the first or second sets comprises receiving an attribute that falls above or below a predetermined threshold.

9. The one or more computer-readable media of claim 1, wherein the method further comprises:

associating the medical data group with a first time stamp;

duplicating the medical data group to create a second medical data group, wherein the medical data group includes assessment data, and duplicating the medical group includes copying the assessment data from the medical data group to the second medical data group;

associating the second medical data group with a second time stamp; and

displaying the second medical data group.

10. The one or more computer-readable media of claim 9, wherein the medical group includes dynamic data and duplicating the dynamic data includes updating the dynamic data in the second medical data group via a medical device interface.

11. The one or more computer-readable media of claim 1, wherein the method further comprises:

indicating that at least one of the medical documentation elements in the second medical document set is linked to a third medical documentation set having a third set of medical documentation elements and a third set of medical data fields to indicate a medical aspect for which medical data is to be documented;

receiving a selection of at least one of the linked medical documentation elements in the second set;

presenting the third set of medical documentation elements and medical data fields in response to receiving the selection;

indicating that an attribute is required for at least one of the medical data fields in the third set; and

receiving an attribute for at least one of the medical data fields in the first, second, or third set.

12. The one or more computer-readable media of claim 1, wherein presenting a first medical documentation set comprises presenting a first medical document set having at least two sections, wherein the link to the second medical documentation set is displayed in both sections.

13. The one or more computer-readable media of claim 1, wherein presenting a first medical documentation set comprises displaying a first medical document set having a plurality of sections, each section having a link to a separate second medical documentation set.

14. The one or more computer-readable media of claim 1, wherein receiving an attribute for at least one of the medical data fields in the first or second set comprises receiving medical data within the medical data fields, wherein the medical data is documented at a point of care in association with medical care provided to a patient.

15. A user interface embodied on at least one computer storage media, the user interface facilitating the completion of medical documentation, the user interface comprising;

a display area displayed on the display of a computer device comprising;

a first medical documentation set display area configured to display a first medical documentation set having a first set of medical documentation elements and a first set of medical data fields to indicate a medical aspect for which medical data is to be documented;

a trigger indicator, selection of which initiates an association between the first medical documentation set and a second medical documentation set;

a second medical documentation set display area configured to display a second medical documentation set having a second set of medical documentation elements and a second set of medical data fields associated with the first medical documentation set;

a medical data group display area configured to receive attributes associated with the first and the second medical documentation sets and aggregate the attributes into a medical data group; and

an unchart display area configured to enable a user to remove attributes from the medical data group display area;

wherein the unchart display area displays the attributes including one or more of a medical label name, a date/time, a creator and a status of the medical label and a reason for uncharting and wherein enabling a user to remove attributes comprises selecting an indicator indicating that the attribute is to be uncharted and wherein the reason for uncharting is subsequently displayed in the corresponding medical documentation element.

16. The user interface of claim 15 further comprising a modification display area configured to indicate that an attribute in the medical data group was modified from an original entry.

17. The user interface of claim 15 further comprising a required field display area configured to indicate that an attribute is required for a medical data field in the first or second medical documentation set.

18. The user interface of claim 15 further comprising a multiple section display area configured to display a plurality of sections, wherein at least two of the sections have at least one first medical documentation set display area, at least one trigger display area, at least one second medical documentation set display area, and at least one medical data group display area.

19. One or more computer storage media having computer-executable instructions embodied thereon for performing a method in a clinical computing environment that guides a clinician to complete medical documentation, the method comprising:

presenting a first medical documentation set having a first set of medical documentation elements and a first set of medical data fields to indicate a medical aspect for which medical data is to be documented;

indicating that at least one of the medical documentation elements in the first set is linked to a second medical documentation set having a second set of medical documentation elements and a second set of medical data fields to indicate a medical aspect for which medical data is to be documented;

receiving a selection of at least one of the linked medical documentation elements in the first set;

presenting the second set of medical documentation elements and medical data fields in response to the selection;

receiving an attribute for at least one of the medical data fields in the first or second set;

aggregating the attributes received for the first and the second medical documentation sets into a medical data group;

associating the medical data group with a first time stamp and displaying the medical data group;

duplicating the medical data group to create a second medical data group, wherein the medical data group includes assessment data and dynamic data, and duplicating the assessment data includes copying the assessment data from the medical data group to the second medical group and duplicating the dynamic data includes updating the dynamic data in the second group via a medical device interface;

associating the second medical data group with a second time stamp and displaying the second medical data group; and

enabling a clinician to view result details for any uncharted labels; and

presenting an unchart display area configured to enable a user to remove attributes from the medical data group display area;

wherein the unchart display area displays the attributes including one or more of a medical label name, a date/time, a creator and a status of the medical label and a reason for uncharting and wherein enabling a user to remove attributes comprises selecting an indicator indicating that the attribute is to be uncharted and wherein the reason for uncharting is subsequently displayed in the corresponding medical documentation element.