Multi-modal entry for electronic clinical documentation

• US 9,069,746 B2
• Filed: 02/27/2012
• Issued: 06/30/2015
• Est. Priority Date: 01/24/2007
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Ash, Michael A., Deverter, John Q., Pagadala, Pramod
• Primary Examiner(s): TANK, ANDREW L
• Application Number:
  US13/406,255
• Publication Number:
  US 20120159316A1
• Time in Patent Office: 1,219 Days
• Field of Search: 715209-210, 715/221, 715/224, 715/256, 715/704, 715/711, 715/716, 715727-729, 715/789, 715/802, 715/809, 715/811, 715/816, 715/821, 715232-233, 704/235, 704/270, 704/234
• US Class Current: 1/1
• CPC Class Codes: G06F 40/174 Form filling; Merging
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

Methods, computer-readable media, and systems for populating an electronic clinical document capable of receiving multiple types of data are provided. In one embodiment, dictation audio input is embedded directly into one or more sections of an electronic clinical document along with other data types, such as structured user input, free-text input, or system-generated input. An electronic clinical document having embedded dictation audio and other data types can receive transcribed text corresponding to the embedded dictation audio.

Claims

1. A method in a computerized healthcare system for populating an electronic clinical document, the method comprising:

providing an electronic clinical document for a particular patient, the electronic clinical document being capable of receiving dictation audio input, structured user input, free-text input, and system-generated input;

receiving dictation audio input into the electronic clinical document, wherein the dictation audio input is audio data;

receiving at least one of structured user input, free-text input, and system-generated input into the electronic clinical document;

embedding the dictation audio input directly into the electronic clinical document;

presenting representations indicative of each of the embedded dictation audio input in the electronic clinical document; and

assigning a dictation audio identifier to each of the representations, wherein the dictation audio identifier associates the dictation audio input with the particular patient, the electronic clinical document, and a location of the dictation audio input within the electronic clinical document.

2. The method of claim 1, wherein the electronic clinical document comprises a plurality of sections.

3. The method of claim 2, wherein the dictation audio input and the at least one of structured user input, free-text input, and system-generated input are received into one of the plurality of sections of the electronic clinical document.

4. The method of claim 2, wherein the plurality of sections are displayed in a common user interface.

5. The method of claim 2, wherein the plurality of sections are displayed within a single tab.

6. The method of claim 2, wherein the plurality of sections are displayed within a single-screen view.

7. The method of claim 1, wherein the dictation audio input is received into at least two of the plurality of sections of the electronic clinical document.

8. The method of claim 1, further comprising receiving a transcribed body of text associated with the dictation audio input.

9. The method of claim 8, further comprising receiving additional dictation audio input into the transcribed body of text.

10. One or more computer storage media having computer executable instructions embodied thereon for performing a method in a computerized healthcare system for populating an electronic clinical document having a plurality of sections, the method comprising:

providing an electronic clinical document for a particular patient having a plurality of sections, at least one of the plurality of sections being capable of receiving input of multiple data types;

receiving dictation audio input into at least two of the plurality of sections, wherein the dictation audio input is audio data;

embedding the dictation audio input directly into each of the at least two of the plurality of sections;

presenting representations indicative of the embedded dictation audio input in association with each of the at least two of the plurality of sections; and

associating the dictation audio input with the particular patient, the electronic clinical document, and locations of the dictation audio input within the electronic clinical document.

11. The computer storage media of claim 10, wherein the at least one of the plurality of sections that is capable of receiving input of multiple data types is capable of receiving at least dictation audio input, structured user input, free-text input, and system-generated input.

12. The computer storage media of claim 10, wherein the method further comprises receiving at least one of structured user input, free-text input, and system-generated input into one of the at least two sections having dictation audio input embedded therein.

13. The computer storage media of claim 12, wherein the method further comprises presenting the at least one of structured user input, free-text input, or system-generated input in association with the section into which it was received.

14. The computer storage media of claim 10, wherein the method further comprises receiving into one or more of the at least two of the plurality of sections, transcribed text associated with the dictation audio input embedded therein.

15. The computer storage media of claim 14, wherein the method further comprises:

presenting the transcribed text within the at least one of the plurality of sections with which the dictation audio input associated with the transcribed text is embedded.

16. The computer storage media of claim 10, wherein the plurality of sections are provided in a common user interface.

17. The computer storage media of claim 10, wherein the plurality of sections are provided in a single-screen view.

18. The computer storage media of claim 10, wherein the plurality of sections are provided within a single tab.

19. One or more computer storage media having computer executable instructions embodied thereon for performing a method in a computerized healthcare system for populating an electronic clinical document having a plurality of sections, the method comprising:

providing an electronic clinical document for a particular patient, the electronic clinical document having a plurality of sections, wherein at least one of the sections is capable of receiving dictation audio input, structured user input, free-text input, and system-generated input, and wherein the plurality of sections are displayed within a single-screen view;

receiving the dictation audio input into the electronic clinical document, wherein the dictation audio input is audio data, and wherein while the dictation audio input is being received into the electronic clinical document, existing data in the electronic clinical document is locked so that read-only access is given to the existing data;

receiving the free-text input into the electronic clinical document;

embedding the dictation audio input directly into each of the at least two of the plurality of sections;

presenting representations indicative of the embedded dictation audio input in association with each of the at least two of the plurality of sections;

providing a dictation audio identifier for each of the representations; and

utilizing the dictation audio identifier to associate the dictation audio input with the particular patient, the electronic clinical document, and a location of the dictation audio input within the electronic clinical document.