Clinical documentation system for use by multiple caregivers

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.

Description

[0001] This application is a continuation of U.S. application Ser. No. 09 / 950,158 filed Sep. 10, 2001, which application claims priority to U.S. Provisional Application Ser. No. 60 / 233,950, filed Sep. 20, 2000, the disclosure of which is hereby expressly incorporated herein by reference.FIELD OF THE INVENTION [0002] The invention relates generally to information management systems for use within the healthcare enterprise, and more particularly, to a system for documenting clinical patient information generated by multiple caregivers. BACKGROUND OF THE INVENTION [0003] During the course of a patient's stay in an inpatient or acute care facility, the patient will be seen by a variety of health care providers as they review the patient's status, recommend treatments and protocols, provide care, order tests, etc. Providers must record all of their activities and decisions for the patient, and efficient communication of this information between all of a patient's caregivers is key to the...

AI Technical Summary

Benefits of technology

The invention is a computer-based system for recording, storing, and accessing clinical documentation in an acute care setting. The system aims to address the need for efficient communication between a patient's caregivers and to provide a single point of access to the information recorded by all caregivers during an acute care episode. The system addresses various needs such as providing simultaneous access to a patient's chart for both viewing and editing from different locations while maintaining data integrity, providing role-based security, and incorporating available information relevant to a patient's acute care episode. The system includes a graphic user interface and various functions such as adding, editing, or deleting patient notes, filtering patient notes, and printing or copying patient notes. Overall, the invention provides a more efficient and effective way to manage clinical documentation in healthcare settings.

Problems solved by technology

A shared paper chart kept in or near the patient's room represents perhaps the most common but also the least effective approach.

A shared paper chart offers very limited security and virtually no simultaneous access for either viewing or editing the patient's hospital record.

What's more, as information is eventually added to the patient's record from a large number of caregivers, it becomes increasingly difficult and time consuming to identify and review appropriate information for a particular situation.

However, these systems typically demonstrate weaknesses and problems that result in a failure to ensure efficient communication between a patient's acute caregivers.

Problems with these systems include a failure to address one or more of the following needs:

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