Association of data entries with patient records, customized hospital discharge instructions, and charting by exception for a computerized medical record system

• US 8,392,216 B2
• Filed: 07/15/2005
• Issued: 03/05/2013
• Est. Priority Date: 07/16/2004
• Status: Expired due to Fees

• Current Assignee: Picis Incorporated (Constellation Software Incorporated)
• Original Assignee: Picis Incorporated (Constellation Software Incorporated)
• Inventors: Crockett, Mark D.
• Primary Examiner(s): NGUYEN, HIEP VAN
• Application Number:
  US11/182,497
• Publication Number:
  US 20060036472A1
• Time in Patent Office: 2,790 Days
• Field of Search: 705/3
• 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 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients

Abstract

Apparatus and a method for associating an electronic patient record with the corresponding patient are described. A data processor accesses a patient record not associated with a unique person and compares the patient identification data to corresponding data in a known patient record to identify a set of likely matching patients. An input is provided for selecting a matching patient. Also disclosed is apparatus for providing customized patient discharge instructions relating information in the electronic patient record to patient-specific discharge instructions. A data processor inserts the patient specific instructions into draft instructions, thereby producing patient-specific discharge instructions. An updated version of charting by exception is disclosed, using macros to positively record data on a medical record that is not specifically marked on a template by the attending medical professional. Also described is an apparatus for translating a visual documentation language, communicating specific medical concepts in a highly compact form, to clinically relevant English, enhancing the usability of a pen/digital camera combination for data entry.

Claims

1. An electronic medical charting system comprising:

a user interface presenting a medical chart template, the medical chart template comprising;

a plurality of recording areas configured to enable a user to enter predetermined categories of data reflecting a patient'"'"'s condition; and

a charting by exception recording area configured to enable a user to enter an indication that at least one predetermined category of data on the medical chart template has been reviewed, and is normal, unless an entry other than normal has been recorded in the corresponding recording area for said at least one predetermined category;

a data processor programmed to, when the indication is entered in the charting by exception area;

review at least one predetermined recording area of the medical chart,

identify a recording area of said at least one predetermined recording areas where no data indicating abnormality has been entered, and

make a record that a predetermined category of data corresponding to the identified recording area is normal.

2. The medical charting system of claim 1, wherein the at least one predetermined category of data identified by said data processor is customizable based on an identifier of a physician.

3. The medical charting system of claim 2, wherein a plurality of sets of predetermined categories are defined.

4. The medical charting system of claim 3 wherein said data processor selects a particular set of predetermined categories in a given instance based on information indicating an identity of a medical professional who entered data in at least one of the plurality of recording areas of said medical chart template.

5. The medical charting system of claim 3, where said data processor selects a particular set of predetermined categories in a given instance based on information indicating an identity of a medical professional who entered data in the charting by exception recording area.

6. The medical charting system of claim 3, where said data processor selects a particular set of predetermined categories in a given instance based on the indication made in the charting by exception recording area.

7. The medical charting system of claim 1, wherein the medical chart template further comprises:

a plurality of charting by exception recording areas, each charting by exception recording area being respectively associated with a different set of at least one predetermined category of data on the medical chart template to be entered as normal unless an entry has been recorded in the corresponding recording area.

8. The medical charting system of claim 1, where said charting by exception recording area comprises a position-encoded surface.

9. The electronic medical charting system of claim 1, wherein the data processor is further adapted to:

identify a second recording area of said at least one predetermined recording areas where data indicating abnormality has been entered; and

make a record that a second predetermined category of data corresponding to the identified second recording area is abnormal.

10. The medical charting system of claim 1, wherein:

the charting by exception recording area comprises a plurality of input fields each configured to receive input indicating that at least one predetermined category of data on the medical chart template has been reviewed, and is normal, unless an entry other than normal has been recorded in the corresponding recording area for said at least one predetermined category; and

different predetermined categories are associated different input fields of the plurality of input fields.

11. The medical charting system of claim 10, wherein:

the plurality of input fields comprise an input field associated with a male patient and an input field associated with a female patient.

12. The medical charting system of claim 10, wherein:

the plurality of input fields comprise an input field associated with a user of the system;

the at least one predetermined category associated with the input field associated with the user are customized by the user.

13. A method of recording medical information on an electronic medical record for a patient, the method comprising:

providing a user interface comprising a medical chart template, the template comprising;

a plurality of recording areas configured to enable a user to enter predetermined categories of patient data reflecting a condition of the patient; and

a charting by exception recording area configured to enable the user to indicate that at least one predetermined category of patient data on the template has been reviewed, and is normal when no entry is made in a corresponding recording area of the plurality of recording areas;

receiving through the user interface an entry in each recording area of a first set, the first set comprising recording areas of the plurality of recording areas and each entry indicating that a predetermined category of data corresponding to the recording area is abnormal;

entering in the electronic medical record, with at least one processor, for each recording area in the first set, information based on the entry received in the recording area, the information documenting the abnormality in a correspond category of the predetermined categories of patient data;

receiving through the user interface an indication in said charting by exception recording area that predetermined categories of data that have not been documented on the medical chart template as abnormal should be documented as normal; and

based on the indication received in said charting by exception recording area, entering in the electronic medical record, with at least one processor, for each recording area in a second set, information indicating normal data in a correspond category of the predetermined categories of patient data, the second set comprising recording areas of the plurality of recording areas for which there is received no entry indicating that a predetermined category of data corresponding to the recording area is abnormal.

14. The method of claim 13, wherein:

the user interface comprises a position encoded surface; and

said plurality of recording areas are areas of the position encoded surface.

15. The method of claim 14, wherein said receiving steps comprise receiving from a marking instrument configured to mark on said position-encoded surface with a marking instrument.

16. The method of claim 15, wherein said marking instrument further comprises a data capture device configured to determine what marks have been made in said plurality of recording areas and configured to transmit data reflecting said marks to an electronic medical record system.

17. At least one non-transitory computer readable medium comprising computer-executable instructions that, when executed on at least one processor of a device, perform a method of updating an electronic medical record for a patient, the method comprising:

receiving through a user interface comprising a medical chart template;

first data entered through a first portion of a plurality of recording areas configured to enable a user to enter predetermined categories of patient data reflecting a condition of the patient; and

an indication entered through a charting by exception recording area, the indication indicating that at least one category of patient data on the template associated with the charting by exception recording area has been reviewed, and is normal when no entry is made in a corresponding recording area of the plurality of recording areas;

entering the first data in the electronic medical record; and

based on the indication received in said charting by exception recording area, entering in the electronic medical record for each recording area associated with the charting by exception recording area for which no entry is made, information indicating normal data.

18. The at least one non-transitory computer readable medium of claim 17, wherein:

the user interface comprises a position encoded surface; and

said plurality of recording areas are areas of the position encoded surface.

19. The at least one non-transitory computer readable medium of claim 18, wherein said receiving steps comprise receiving from a marking instrument configured to mark on said position-encoded surface with a marking instrument.

20. The at least one non-transitory computer readable medium of claim 19, wherein said marking instrument further comprises a data capture device configured to determine what marks have been made in said plurality of recording areas and configured to transmit data reflecting said marks to an electronic medical record system.

21. The at least one non-transitory computer readable medium of claim 17, wherein the computer executable instructions further comprise instructions for:

receiving user input defining the at least one category of patient data on the template associated with the charting by exception recording area.

22. The at least one non-transitory computer readable medium of claim 17, wherein the method further comprises determining the at least one category of patient data on the template associated with the charting by exception recording area based on an identity of a user of the device.