Data processing: financial – business practice – management – or co – Automated electrical financial or business practice or... – Health care management
Reexamination Certificate
1999-01-27
2001-02-20
Trammell, James P. (Department: 2764)
Data processing: financial, business practice, management, or co
Automated electrical financial or business practice or...
Health care management
C235S375000
Reexamination Certificate
active
06192345
ABSTRACT:
FIELD OF THE INVENTION
The invention is related to the field of generating medical progress notes for entry into a patient's file.
BACKGROUND ART
The generation of medical progress notes entered into a patient's file is required for good patient medical care and more recently for payment for rendered medical care from medical insurance companies, Medicare or any other agency. Over the years, the S.O.A.P. format has been developed to achieve continuity and repeatability. S.O.A.P. is an acronym for the four steps used in medical record documentation for a doctor-patient encounter.
S.O.A.P. stands for
Subjective
Objective
Assessment and
Plan.
Currently the individual components of the S.O.A.P. format are handwritten or typed by the physician, dictated, or entered by means of bar coded notes or a voice recognition system. The medical record often lacks continuity and consistency. The time spent in the preparation of the medical documentation detracts from quality time available with the patient. For example, handwriting or dictation of the progress note is obviously the most time consuming of the above-enumerated methods. The bar-coded method requires the doctor to locate the desired sentence or phrase on a wall chart or bar code book having hundreds of words and phrases to choose from. The doctor must then choose the appropriate bar code using a bar code reader to enter the selected word or phrase into a word processor. Current word recognition systems require extremely slow and clearly enunciated speech that can be more time consuming and frustrating for the physician. Like hand written notes, the methods using voice recognition may also result in inconsistencies in describing the same observation assessment or plan for two different patients having the same symptoms.
Computer implementation of various health care procedures and bookkeeping are known in the healthcare industry. For example, Ertel in U.S. Pat. No. 5,307,262 is directed to a method and system to review and control clinical data quality in the reporting of hospital claim data. In particular, as stated in the summary of the Ertel patent, the system utilizes the effeciency of batch operations to analyze claim data or entire groups of patients for the purpose of identifying and correcting both case specific and systematic problems in data quality in the most efficient way possible. Although the system taught by Ertel requires the entry of diagnostic and procedure codes into the system, the codes used by Ertel relate to medical billing and are only used in combination with Medicare's “Diagnosis Related Group” program that assigns a diagnosis-related group and to assign several secondary attributes to the patient data sets along with the actual clinical data being entered. The Ertel system is unrelated to a method of generating office progress notes, of the type entered into a private patient file for the purpose of recording the ongoing events of the doctor-patient relationship in the medical office setting. In the medical office, billing is a separate issue from documentation of the patient's progress.
SUMMARY OF THE INVENTION
The invention is a method for generating medical notes using codes indicative of a patient-doctor encounter. The method begins with the doctor preparing a set of codes and supplementary notations subsequent to the patient-doctor encounter. Each code and supplemental notation identifying a frequently used event in a medical office. The prepared codes and supplemental notations are then entered into a programmed computer to generate printable progress notes identified by the entered set of codes and supplementary notations. The program stores the text of the progress notes in sentence form. The stored text of the progress notes being addressable by the codes and supplementary notations. The printed progress notes are then reviewed by the doctor and after his signature approval, entered into the patient file.
In the preferred embodiment, the printed medical progress notes are prepared using the standard S.O.A.P. format. In an alternate embodiment, the medical progress notes are printed on an adhesive-backed paper and pasted on an existing page in the office patient file.
An object of the invention is to provide a method for markedly reducing the time required to generate medical progress notes.
Another object of the invention is to provide a thorough and universally acceptable description of a doctor-patient encounter.
Yet another object of the invention is to provide easily adaptable (customizable) progress notes describing a doctor-patient encounter.
Another object of the invention is that the codes are a natural expression of the doctor via a simple “thought process.”
Still another object of the invention is to allow the doctor to function, for the most part, without having to memorize or look up the codes on a chart. This is feasible via the use of codes designed on a basis of a logical “thought-process format” alluded to in the previous paragraph.
These and other objects of the invention will become apparent from a detailed reading of the Specification.
REFERENCES:
patent: 5296688 (1994-03-01), Hamilton et al.
patent: 5307262 (1994-04-01), Ertel
patent: 5737539 (1998-04-01), Edelson
patent: 5772585 (1998-06-01), Lavin et al.
patent: 5802495 (1998-09-01), Goltra
patent: 5974389 (1999-10-01), Clark et al.
Trace et al., “An intelligent progress note system for MEDAS”, from 3rd annual IEEE symposium on computer-based medical systems, pp. 484-491, 1990.
Trace et al., “A productive user environment for generating progress notes”, from 5th annual IEEE symposium on computer-based medical systems, pp. 486-493, 1992.
Meldman, “Microprocessor technology for psychiatrists”, from IEEE Xplore web site of non-patent literature, pp. 216-220, 1978.
Ma et al., “An intelligent hypermedia system for generating progress notes and physician reminders”, from 6th annual IEEE symposium on computer-based medical systems, pp. 165-170, 1993.
Inada et al., “Fundamental study on adhesive strength of electrical conductive adhesives (ECAs)”, from 1998 International symposium on advanced packaging materials, pp. 268-271, 1998.
Tasukamoto et al., “Electrical aging of adhesive”, from IEEE Xplore web site of non-patent literature, pp. 168-172, 1998.
Greenberg, David S.; The Application of future technologies to medical informatics. Physicial Executive, v20, n1, p5 (5),Jan. 1994, USA.
Larimore, Walter I.; Jordan, Elizabeth V.; Soap to Snocamp: improving the medical record format; Journal of Family Practice, v41,n4,p393(6); USA.
Wyat, Jeremy Crispin;Data and medical records. (Clinical Data Systems, part 1); The Lancet, v344,n8936,p1543 (5); USA.
Nguyen Cuong H.
Trammell James P.
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