Systems and methods for documenting medical findings of a physical examination

• US 8,712,791 B2
• Filed: 11/23/2001
• Issued: 04/29/2014
• Est. Priority Date: 11/22/2000
• Status: Expired due to Fees

• Current Assignee: Recare Incorporated
• Original Assignee: Catalis, Inc.
• Inventors: Dahlin, Michael D., Wohl, Eric, Lipscher, Randolph B
• Primary Examiner(s): Najarian, Lena
• Assistant Examiner(s): PASS, NATALIE
• Application Number:
  US09/992,036
• Publication Number:
  US 20040078215A1
• Time in Patent Office: 4,540 Days
• Field of Search: 705/2, 705/3, 705/4, 705/8, 600/300, 600/437, 600/411, 600/104, 715/853, 715/807, 715/766, 715/788, 715/762, 715/234, 715/205, 707/104.1, 707/102, 345/173, 345/441
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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 70/60 relating to pathologies

Abstract

An electronic system and a method for efficiently documenting medical findings that consist of both a problem and a location on or in the body. This invention further provides a method for documenting multiple problems in related body locations. This invention further provides a method for efficiently issuing orders associated with medical findings that consist of both a problem and a location on or in the body. The invention is able to enhance efficiency during the Physical exam making the invention an essential component of the physician'"'"'s practice workflow. This, in turn, will enable the invention to serve as a single point of integration for a vast array of useful electronic tools and information. For example, in a computer-implemented system and method for documenting one or more medical findings having a body location and a type of medical finding, the method includes the steps of: displaying a body location selection view for a user, the user selecting a body location, the system then displaying a means of selecting possible types of medical findings, the system also then displaying a means of selecting to display a more detailed body location selection view, wherein the user selecting a type of medical finding causes the system to store a finding comprising the user-selected location and problem, and wherein the user selecting to display a more detailed body location selection view causes the system to display a more detailed body location selection view. The method may further include the finding types that may be selected are of a group of finding types and further comprising a means for selecting a different group of finding types to be displayed. Moreover, the groups of finding types each may correspond to a set of finding types related to one system of the body. The system may include a means for selecting one or more appropriate procedures that may be performed at the selected body location and a means for recording an annotation regarding the selected location of the body. The means for recording an annotation may be selected from a group including selecting a pre-generated annotation, recording a text annotation, recording a graphical annotation, recording a sound annotation, and recording a photographic annotation.

Claims

1. A method for documenting medical findings of a physical examination, the method comprising:

displaying on an interface device a first interface including a first graphical representation of anatomical features;

accepting from a user via the interface device a first selection of an anatomical feature by clicking on a specific part of the anatomical feature on the first graphical representation of anatomical features;

displaying on the interface device a second interface including a second graphical representation of anatomical features and a first set of controls relating to a first plurality of medical conditions in response to accepting the first selection, the second graphical representation of anatomical features and the first set of controls displayed simultaneously without at least partially obstructing each other;

accepting from the user via the interface device a second selection from the second graphical representation of anatomical features; and

displaying on the interface device a third interface including a second set of controls relating to a second plurality of medical conditions;

wherein the first set of controls includes a tri-state control comprising one graphical icon configured to indicate one of three states including present, not present, or not entered,

the method further comprising;

accepting from the user via the interface device an indication of a state of not present, the indication resulting from the user selecting the graphical icon twice and wherein the graphical icon displays a state of not entered for an empty box, a state of present for a checkmark, and a state of not present for a slash mark; and

storing data associating the state accepted from the user with the first selection and displaying the state accepted from the user in a list of findings.

2. The method of claim 1, wherein the first graphical representation of anatomical features includes a graphical representation of a plurality of body locations.

3. The method of claim 2, wherein the first selection comprises a response indicative of one of the plurality of body locations.

4. The method of claim 1, wherein the step of displaying the first interface and the step of displaying the second interface take place in different views.

5. The method of claim 1, wherein displaying the second interface comprises displaying the second graphical representation in response to the first selection by the user, the first selection indicating a portion of anatomical features associated with the first graphical representation to be displayed, the second graphical representation including the portion of the anatomical features with greater detail.

6. The method of claim 1, wherein the second interface includes a drill down button.

7. The method of claim 1, wherein the second interface includes a change system button.

8. The method of claim 7, further comprising displaying a list of systems associated with the first selection in response to a user selection of the change system button.

9. The method of claim 1, wherein the second interface includes a procedure button.

10. The method of claim 9, further comprising displaying a list of procedures associated with the first selection in response to a user selection of the procedure button.

11. The method of claim 1, wherein the first set of controls includes an annotation control.

12. The method of claim 1, wherein the second plurality of medical conditions represents a greater level of detail than the first plurality of medical conditions.

13. The method of claim 1, wherein the second interface and the third interface include a list of recent findings.

14. The method of claim 1, wherein displaying the first interface, displaying the second interface, and displaying the third interface are performed on a wireless tablet computer including the interface device and configured for use by a physician.

15. The method of claim 1, further comprising

accepting from the user via the interface device a third selection, the third selection including changing one control of the first set of controls;

and

combining the first selection and the third selection to derive at least one medical finding.

16. The method of claim 1, wherein the second graphical representation of anatomical features and the first set of controls are simultaneously active.

17. A device for documenting medical findings of a physical examination, the device comprising:

an electronically readable media for storing instructions;

a processor, associated with the electronically readable media, that executes the instructions; and

the instructions comprising;

instructions for displaying a first interface including a first graphical representation of anatomical features;

instructions for accepting from a user a first selection of an anatomical feature by clicking on a specific part of the anatomical feature on the first graphical representation of anatomical features;

instructions for displaying a second interface including a second graphical representation of anatomical features and a first set of controls relating to a first plurality of medical conditions in response to accepting the first selection, the second graphical representation of anatomical features and the first set of controls displayed simultaneously without at least partially obstructing each other, wherein the first set of controls includes a tri-state control comprising one graphical icon configured to indicate one of three states including present, not present, or not entered;

instructions for accepting from the user an indication of the state of not present, the indication resulting from the user selecting the graphical icon twice and wherein the graphical icon displays a state of not entered for an empty box, a state of present for a checkmark, and a state of not present for a slash mark;

instructions for storing data associating the state accepted from the user with the first selection;

instructions for displaying the state accepted from the user in a list of findings;

instructions for accepting from the user a second selection from the second graphical representation of anatomical features; and

instructions for displaying a third interface including a second set of controls relating to a second plurality of medical conditions.

18. The device of claim 17, wherein the first graphical representation of anatomical features includes a graphical representation of a plurality of body locations.

20. The device of claim 17, wherein the instructions for displaying the first interface and the instructions for displaying the second interface effect different views.

21. The device of claim 17, wherein the instructions for displaying the second interface comprise instructions for displaying the second graphical representation in response to the first selection by the user, the first selection indicating a portion of the anatomical features associated with the first graphical representation to be displayed, the second graphical representation including the portion of the anatomical features in greater detail.

22. The device of claim 17, wherein the second graphical representation of anatomical features and the first set of controls are simultaneously active.

19. The device of 18, wherein the first selection comprises a response indicative of one of the plurality of body locations.

23. A method for documenting medical findings of a physical examination, the method comprising:

displaying on an interface device a first interface including a first graphical representation of anatomical features;

accepting from a user via the interface device a first selection of an anatomical feature by clicking on a specific part of the anatomical feature on the first graphical representation of anatomical features;

displaying on the interface device a second interface including a second graphical representation of anatomical features and a first set of controls relating to a first plurality of medical conditions in response to accepting the first selection, the second graphical representation of anatomical features and the first set of controls displayed simultaneously without obstructing each other, wherein the second graphical representation of anatomical features and the first set of controls are simultaneously active, wherein the first set of controls includes a tri-state control comprising one graphical icon configured to indicate one of three states including present, not present, or not entered;

accepting from the user via the interface device an indication of a state of not present, the indication resulting from the user selecting the graphical icon twice and wherein the graphical icon displays a state of not entered for an empty box, a state of present for a checkmark, and a state of not present for a slash mark;

combining the first selection and the state accepted from the user to derive at least one medical finding;

storing the at least one medical finding;

displaying the at least one medical finding in a list of findings;

accepting from the user via the interface device a second selection from the second graphical representation of anatomical features; and

displaying on the interface device a third interface including a second set of controls relating to a second plurality of medical conditions.