Visual charting method for creating electronic medical documents

Abstract

A method of creating medical documentation uses selection of images representing synonyms for complex medical concepts. The images can be of two types, one corresponding to a parameter or Key in a Key / Value pair and the other corresponding to possible values of the selected parameter or Key. The user first selects an image or portion thereof corresponding to the parameter they wish to record observations, such as the heart or a valve of the heart. A set of images representing possible values of the parameter is then displayed e.g., images representing possible murmurs the selected valve may have. The user selects the image representing the value corresponding to the observation of the patient. A document is created by recording either the Key / Value image pairs or, alternative, text representing the synonyms for the images. Other methods of recording the document are possible, such as instantiating a set of class objects.

Description

BACKGROUND[0001]1. Field[0002]This invention relates generally to the field of computerized systems for storing and creating electronic records, and in particular to methods and systems for creating medical documentation regarding a patient.[0003]2. Description of Related Art[0004]In the medical arena, hand written patient record keeping systems have evolved through many years of careful refinement and enhancement into systems which maintain a detailed manual record of medical information concerning each patient. To meet the needs of different hospital entities (such as doctors, nurses, pharmacy, accounting, laboratory, etc.) a manual record keeping system often requires that one piece of information be entered into multiple records. In addition it often requires that the same information that has not changed from visit to visit (such as family / social history, allergies, immunization status) be re-asked of the patient and re-documented in the current record. In certain instances, su...

AI Technical Summary

Benefits of technology

[0011]This invention meets a long-felt need in the art for a method for creating medical documentation more quickly than traditional text-based approaches. In particular, this invention provides a visual, symbolic approach to creating documents, referred to herein as “visual charting.” In visual charting, complex medical concepts are presented on a user interface display as symbols which are selected by the physician as part of a medical documentation creation process. The symbols are, in essence, synonyms for a textual description of the complex medical concept. By means of selection of symbols, and in preferred embodiments a sequence of such symbols, the visual charting method preserves the complexity and nuance in the content of a medical document that text-based approaches provide, while substantially reducing the amount of time it takes the practitioner to create the documentation. In essence, medical charting concepts requiring the recording of detailed information can be represented by specific images, the selection of which allowing medical documentation to be created in a more efficient manner.

Problems solved by technology

This process can be very inefficient since notations may be forgotten or not copied appropriately.

Often, such observations may encompass complex medical concepts.

A text-based approach to creating such documentation (i.e., typing in all of the clinical observations) is time consuming and inefficient.

Images