Clinical documentation system for use by multiple caregivers

• US 20020062229A1
• Filed: 09/10/2001
• Published: 05/23/2002
• Est. Priority Date: 09/20/2000
• Status: Active Grant

• Current Assignee: Epic Systems Corporation
• Original Assignee: Epic Systems Corporation
• Inventors: Alban, Christopher, Seow, Khiang
• Granted Patent: US 7,251,610 B2
• Time in Patent Office: Days
• 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, provider data and user information; and

an interface coupled to the health record system including a graphic display, the interface operable to retrieve, based upon the user information, 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 display.

2. The system of claim 1, wherein the interface further comprises an editor operable with the interface to facilitate editing of the patient note data within the graphic display.

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

4. The system of claim 2, wherein the editor is operable independent of the depiction of the patient note data within the graphic display.

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

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

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

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

author, author type and time.

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

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

11. The system of claim 1, further comprising a second interface including a graphic display coupled to the health record system, the second interface operable to retrieve, based upon the user information, patient note data associated with the specified patient, and to graphically depict the patient note data in list form and text form within the second graphic display.

12. 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.

13. The system of claim 12, wherein the patient note data includes tag data, and wherein the searcher is operable on the tag data.

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

15. The system of claim 14, wherein the cosign data comprises a cosign from at least one caregiver.

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

17. The system of claim 1, wherein the patient note data comprises soft delete data.

19. The method of claim 18, 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

20. The method of claim 18, further comprising editing the patient note data.

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

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

23. The method of claim 18, further comprising the steps of:

providing a second interface coupled to the health record system, the second interface including a second graphic display, and

for the patient, listing the patient note data in a first portion of the graphic display and text linked with the patient note data in a second portion of the graphic display.

24. The method of claim 23, comprising editing a portion of the patient note data via the interface and concomitantly inhibiting editing of the portion via the second interface.

25. The method of claim 18, 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.

26. The system of claim 18, 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.

27. The system of claim 18, 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.

28. The system of claim 18, 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.

18. 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 patient note data from a plurality of caregivers and storing the patient note data in at least one of the data structures;

providing an interface coupled to the health record system, the interface including a graphic display, and

for a patient, listing the patient note data in a first portion of the graphic display and text linked with the patient note data in a second portion of the graphic display.