Generating and managing medical documentation sets

• US 8,150,711 B2
• Filed: 10/02/2008
• Issued: 04/03/2012
• Est. Priority Date: 10/05/2007
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Kelly, Lisa, Gannon, Mary, Gerling, Martha, Rogers, Stephanie
• Primary Examiner(s): O'Connor, Gerald J.
• Assistant Examiner(s): Pauls, John
• Application Number:
  US12/244,439
• Publication Number:
  US 20090094061A1
• Time in Patent Office: 1,279 Days
• Field of Search: 705/2, 705/3, 128/920
• US Class Current: 705/3
• CPC Class Codes: G06F 40/186 Templates
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 10/20 for electronic clinical trials or questionnaires
• 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 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 40/63 for local operation

Abstract

Methods, computer storage media, systems and user interfaces for generating and/or managing medical documentation sets are provided. Medical documentation sets are generated by replicating a predetermined medical template. After the predetermined medical template is replicated, the medical label associated with the medical documentation set may be modified so that the medication documentation set includes a unique medical label. Upon the completion of a medication documentation set, it may be retrieved and managed as desired.

Claims

1. A method for generating medical documentation sets, the method comprising:

receiving an indication to present a medical documentation set that corresponds with a medical category;

utilizing a medical template associated with the medical category to present the medical documentation set within a first documentation view, the medical documentation set comprising;

a medical label comprising one or more medical label elements, wherein each of the one or more medical label elements indicates a category of label terms to use to generate a unique medical label for the medical documentation set,

a set of one or more medical documentation elements that indicate a medical aspect for which medical data is to be documented, and

a set of medical data fields for receiving input of the medical data associated with care provided to a patient at a point of care;

receiving, via a computing device, an indication of a label term within each of the categories of label terms to replace the corresponding medical label element by sequentially receiving a selection of the label term from a list of label terms that are presented on the documentation view for each of the categories of label terms;

generating the unique medical label that uniquely identifies the medical documentation set by replacing each of the medical label elements with the corresponding selected label term, the unique medical label comprising a combination of the selected label terms that medically describes care associated with the patient; and

capturing the medical documentation set.

2. The method of claim 1 further comprising receiving a selection of the medical category.

3. The method of claim 1 further comprising generating the medical template.

4. The method of claim 3, wherein generating the medical template comprises:

receiving an indication of the medical category to which the medical template corresponds;

receiving an indication of the one or more medical label elements to include within the medical label of the medical template;

receiving an indication of the set of medical documentation elements to include within the medical template; and

aggregating the one or more medical label elements and the set of medical documentation elements to generate the medical template.

5. The method of claim 1 further comprising presenting a set of label terms for replacing the one or more medical label elements.

6. The method of claim 1 further comprising 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 the patient.

7. The method of claim 6 further comprising automatically determining if the received medical data matches a predetermined attribute and, if so, providing at least one additional medical data field.

8. The method of claim 7 further comprising presenting the medical documentation set within the medical category of a second documentation view.

9. The method of claim 8 further comprising presenting a graph representing data documented within a plurality of medical documentation sets, wherein the data is associated with a specific medical documentation element.

10. A computerized system in a clinical environment for generating medical documentation sets, the system comprising:

a processing unit; and

a memory for storing computer-executable instructions that when executed by the processing unit executes;

a generation indicating component configured to receive an indication to generate a medical documentation set;

a documentation set presenting component configured to present the medical documentation set in accordance with a medical template that includes a set of medical label elements for indicating a group of label terms to use to describe care provided to a patient, a set of medical documentation elements that indicate a medical aspect corresponding to the medical category for which medical data is to be documented; and

a set of medical data fields for initially documenting the medical data associated with the care provided to the patient;

a documentation set labeling component configured to receive an indication of a label term from each group of label terms to replace the corresponding medical label element by receiving a selection of the label term from a list of label terms that are presented for each of the groups of label terms, and to generate a unique medical label that uniquely designates the medical documentation set by replacing each of the medical label elements with the corresponding selected label term, the unique medical label comprising a combination of the selected label terms that medically describes care provided to the patient; and

a capturing component for saving the medical documentation set.

11. The computerized system of claim 10 further comprising a documentation receiving component configured to receive medical data associated with the patient care, wherein the medical data is documented at the point of care.

12. The computerized system of claim 10 further comprising an availability notice presenting component configured to present a medical template availability notice to indicate that the medical template is available to use to generate the medical documentation set.

13. The computerized system of claim 10 further comprising a medical template generation module configured to generate the medical template.

14. The computerized system of claim 13, wherein the medical template generation module comprises:

a template generator presenting component configured to present a medical template generator tool for use by a user to generate the medical template;

an obtaining component configured to obtain the medical category in association with the medical template, the set of medical label elements, and the set of medical documentation elements; and

a template formatting component configured to format the medical template using the set of medical label elements and the set of medical documentation elements.

15. The computerized system of claim 14, wherein the medical template is saved.

16. The computerized system of claim 15, wherein a medical template name is assigned to the medical template.

17. One or more computer storage media having computer-executable instructions embodied thereon for performing a method for generating medical documentation sets, the method comprising:

receiving an indication to generate a medical documentation set for a medical category, wherein the medical documentation set comprises one or more first medical label elements, one or more first medical documentation elements, and one or more first medical data fields;

presenting the medical documentation set among at least one other medical documentation set within the medical category of a first documentation view such that the first documentation view displays the medical documentation set including the one or more first medical label elements, the one or more first medical documentation elements, and the one or more first medical data fields and the at least one other medical documentation set including one or more second medical label elements, one or more second medical documentation elements, and one or more second medical data fields within the first documentation view;

receiving an initial text input of one or more first medical data associated with care provided to a patient at a point of care within the one or more first medical data fields,

wherein when at least one of the one or more first medical data within the one or more first medical data fields comprises a predetermined attribute that is a specific text, value, value range, or symbol, providing one or more third medical documentation elements and one or more third medical data fields that correspond with the one or more third medical documentation elements;

receiving an indication of a label term from each category of label terms to replace a corresponding first medical label element by receiving a selection of the label term from a list of label terms that are presented for each of the categories of label terms;

replacing each of the first medical label elements with the corresponding selected label term to generate a unique medical label that uniquely identifies the medical documentation set, the unique medical label comprising a combination of the selected label terms that medically describes care associated with the patient; and

capturing the medical documentation set.

18. The one or more computer storage media of claim 17 further comprising generating the medical template to use to generate the medical documentation set.

19. The one or more computer storage media of claim 17 further comprising presenting the medical documentation set within the medical category of a second documentation view.

20. The one or more computer storage media of claim 17 further comprising presenting a graph representing data documented within a plurality of medical documentation sets, wherein the data is associated with a specific documentation element.