JPH06218011A - Method to generate and implement integrated plan for caring of patient - Google Patents

Abstract

PURPOSE: To put the completion of a task in a chart without omitting the environments of a task list by opening a window in the lower form and charting a task directly in a form. CONSTITUTION: A hospital information system has a data processing system containing a plural number of terminals 2, which has a display means 3 and data input means, and information regarding patients are inputted in the system by way of the terminals 2, organized hierarchically by the system and can be displayed to a user having an appropriate access toward the system. The system offers a task list generated by the time, which is automatically generated from data inputted on an order from a doctor or a nurse. A task can be put in a chart by the system user without going out of the task list and all the forms concerned are automatically updated.

Description

Detailed Description of the Invention

[0001]

FIELD OF THE INVENTION This invention relates generally to automated hospital information systems and, in particular, to time-sensitive (t) data from data entered by physicians and nursing orders.
An ime-oriented task list is automatically generated and the tasks are charted by the system user directly from said task list with automatic updates of the associated form (s).
d) Relating to hospital information system.

[0002]

The present invention relates to an automated clinical record management system. Such a system relates to an automated clinical record management system. Such a system has utility, for example, in hospital-based patient record-keeping systems. Patient record-retention systems are used to maintain a wide variety of types of medical records for patients in clinics or hospitals.

[0003] Handwritten patient record-keeping systems have evolved over the years with careful polishing and augmentation to maintain detailed manual records of medical information about each patient. In order to meet the needs of different hospital entities (such as doctors, nurses, pharmacies, accounting, laboratories, etc.) that need access to such medical information, in a manual record-keeping system:
Various types of medical information are recorded on many types of records.

In a typical manual patient record-save system, patient charts, usually in the form of a notebook, are stored at the nursing station for each patient. The notebook is divided into multiple individually headed sections, such as physician order, Kardex, nursing care planning, nursing assessment, and laboratory.

Each of the above sections is subdivided into a number of foams. The form is individual patient and / or
Or it is appropriate for the doctor of such a patient. For example, there may be forms for chemistry, hematology, BloodGas, and microbiology within the "Laboratory" section.

In addition, a "flowsheet" chart is usually stored at the patient's bedside. The "flow sheet" chart is generally used for drug records, measurements of important body functions, inhaled / excreted amounts, study results, and if the patient is attached to a ventilator. There are separate areas for other categories, such as respiratory devices, depending on the patient's distress.

One problem with manual patient record-keeping systems is that each associated with a patient is given a relevant personal identifying information such as the patient's name and ID number, bed position, etc. The need to fill out the patient record form separately. This is usually done using an embossed card, similar to a credit card, which contains the patient's personal information. However, this process consumes a certain amount of time and results in errors if the two patient cards are inadvertently replaced.

Another problem with manual patient record-storing systems is that the same information can be stored in different forms in order to meet the various needs of different hospital entities where such patient records are stored for their benefit. It must be recorded in. Again, this involves additional time-consuming work and often results in errors that are accidentally caught in the patient's record. In addition, the desired patient information may not be accessible to legitimate users, which may be stored in a form that such users are unfamiliar with or are currently being accessed by other users. This is because

Yet another problem with manual patient record-keeping systems is that it is difficult to retrieve patient care information for accounting audit and review purposes.
For example, the Joint Committee on the Certification of the Health Care Organization (JC
AH) specifies many different requirements for providing documentation, and it is often difficult to meet such requirements. Therefore, it is possible to have a patient record-keeping system that provides a direct relationship between the physician order and the corresponding documentation for that order (eg, whether the order is complete or is not complete). Would be beneficial.

The salary of nurses is 30% of the operating budget of hospitals.
40%, and they are 25% -40% of their time
It is estimated to spend on administrative and telecommunications work. Due to changes in government regulations, insurance reimbursement policies, and competitive conditions, hospitals are increasingly under pressure to reduce their operating costs. As a result, hospital occupancy and patient stays have decreased and more hospital patients have become more ill. However,
Staff levels are being reduced to cut costs. In addition, there is often a shortage of skilled nurses. Therefore, hospitals are providing care to less ill patients by fewer people, and there is a significant need to make these people more productive with hospital automation.

Various automated medical record-storing systems have been proposed and implemented to maximize productivity of hospital staff and maximize overall patient care by making optimal use of patient data. Has been done.

[0012]

[Problems to be Solved by the Invention] Customer
rs), clients, and even internal / dental patients, are known to have automated record-keeping systems that organize many types of information, including information related thereto. There is no known automated clinical record management system that offers the advantage of error-freeness and that more closely responds to the organization and appearance of traditional, familiar and manual hospital record charting systems.

In known automated hospital record keeping systems, the user interface is typically "machine oriented". In a "machine-generated" system, the system typically waits for the user to issue a command. Users often have to go through several confusing hierarchies of on-screen menus and deeper through the layers toward the desired screen level. Once there, once the user is at what screen level he is working, how he got there, how to get back to a more basic screen level, and how to get a different screen Forgetting to move to a level or to the relevant screen level can all be quite easy for the user.

In a "user friendly" system, the system electronically emulates an existing hospital form on a screen display, and within the environment of the form the user manipulates and reviews information in such form. Provide easily accessible commands to enable you to do that.

It is highly desirable to provide a user with an automated hospital record keeping system with the ability to generate a time-based task list of all tasks that must be performed for each patient. In today's record keeping systems, time-consuming tasks are maintained on a variety of different forms or simply devoted to memory, so that the nurse or other user can chronologically sort the tasks to be performed on each patient. You should try to manually write down or remember the checklist of. Not only is the manual generation of such a list time consuming, but too often errors occur in recording such information or retrieving it from memory. Therefore, it has been found highly desirable to automatically generate a task list from data entered from doctor and nurse or caregiver orders.

In a manual clinical record keeping system, when a nurse performs a task, he / she must not only record the achievements in the associated form from which it occurred. He / she must also record on a manual checklist that the task has been performed. Thus, the tasks in such a task list can be charted by the user of the system while viewing the task list and the associated form (s) are automatically updated as each task on the task list is completed by the user. It is convenient if done. Furthermore, it would be desirable to be able to chart directly from this chronological task list that a particular intervention or procedure was performed without leaving the chronological task list environment.

Furthermore, if a task can be charted directly into one of the system's forms by the system user, and in doing so, the task list and some other related form (s) are automatically updated. Would be desirable.

It is also desirable to automatically record the completion of each task and intervention as it is accomplished in order to complete the document recording request for proper patient care.

Accordingly, the objectives of the present invention are tasks whose format closely resembles that of a manual clinical record management system and which must be accomplished for a patient in response to the entry of orders into the appropriate system form. Automatically generate a time-occurring task list of, and make certain items visible to the user by a form containing such items and without the user leaving the task list. It is to provide an automated clinical record management system that allows direct charting of such forms.

[0020]

In the automated clinical record management system of the present invention, the user of the system charts the completion of tasks.
There are at least two ways you can do it. According to a first method described and claimed herein, the user of the system opens the task list environment by opening windows in the appropriate underlying forms and directly charting the tasks in such forms. You can chart the completion of tasks without leaving. When a user of the system signs a task for completion, the task list and any associated form (s) are automatically updated as the completion of the task is recorded in the underlying form.

Alternatively, the user of the system can chart the completion of the task directly into the appropriate system form, and when the user of the system signs the completion of the task in such form, the task list and any associated The form (s) to be performed are automatically updated as task completions are recorded on the forms of such systems.

Therefore, said and other objects comprise, according to a preferred embodiment of the present invention, a processing unit, a memory unit and at least one terminal unit, said terminal unit providing patient information to the user of the terminal. Generating an integrated plan of care for a patient in a medical information system comprising display means for displaying and input means for a user of the terminal to enter patient information into the system and to command the system. And a method of performing,
(A) displaying the first form on the display means, (b) using the input means, medically related in the form of an action or intervention to be performed on the patient on the first form. Entering an order for a task to be performed, the order being a doctor or nurse,
Input by a person responsible for providing medical care to the patient, (c) automatically transcribing information related to the task into a second form as a result of the order. Thus, the second form comprises a list of related tasks to be performed on the patient and for recording a corresponding indication that the task has actually been performed by a person responsible for performing the task. Including a region, and (d) automatically and substantially instantaneously transcribing information relating to said task to a third form, said third form all to be done with respect to said patient. A list of tasks of the patient, including the related tasks of the second form, and further as a result of a doctor's order or a nurse's order. Includes all other actions and intervening to be that the ordered or order against, (e)
Displaying the third form on the display means to the person responsible for performing the task, (f) using the input means to select the task from the third form, (g) ), Displaying at least a portion of the second form on the display means to the person who is responsible for performing the task, including the information, while at least one of the third forms including the task. Displaying the part, (h) using the input means to input an indication that the task has been performed on the second form, and (i) reflecting that the task has been performed. Automatically and substantially instantaneously to modify the third form to provide a method of generating and implementing an integrated care plan for a patient. It is achieved by Rukoto.

[0023]

The invention is pointed out with particularity in the appended claims. However, other features of the invention will become more apparent and the invention will be best understood by referring to the following detailed description in conjunction with the accompanying drawings.

Patient Care Overview FIG. 1 is a block diagram generally illustrating a patient care process in a typical hospital environment.

The doctor 301 is the patient 3 during the stay in the hospital.
Take responsibility for 15 care and management. Upon admission of a patient to the hospital, the doctor will assess the patient and come to a diagnosis. Based on this diagnosis, the doctor writes a plan of care in his progress note and generates a list of doctor orders 306 to be performed by the nurse and other hospital staff 303. Doctor's order 306 is Kardex 310,
It is the source of Task List 312, Requisition 314, and other related forms that help the overall implementation of patient care plan 302. Nursing order 308 also generates interventions corresponding to cardex 310 and task list 312.

Cardex 310 and task list 3
Other interventions at 12 are dictated by hospital procedures 322, which are hospital standards of care, hospital policies,
And including rules. The nurse and other hospital staff 303 will execute the instructions written in the cardex 310 and task list 312 and then fill in the appropriate forms to meet the requirements to provide the necessary documentation.

Flow sheet 323 and diagnostic result 326
Other forms, such as, document specific measurements, test results, and / or calculations 316 made directly on the patient or patient tissue, fluid, etc. Similarly,
Interventions and other therapies 320 are medical management record form 33.
2 and other forms.

Nursing personnel and physicians observe the results of patient 315 and care and therapy 320 and their observations 318.
Document the progress note 324 and other related forms.

From the observation 318 and the progress note 324, the doctor 310 or caregiver 303 writes a new set of orders 300 corresponding to the current condition of the patient 315.

System Hardware Referring now to FIG. 2, there is shown a block diagram of a typical hardware configuration for implementing the automated clinical recording system of the present invention. Figure 2 shows the Local Area Network (LAN)
1 shows a distributed computer system with multiple workstations or terminals 2, 22, 32, 34 and 85 coupled together.

The system is typically implemented for use in a nursing care unit, such as an intensive care unit, in a hospital or clinic. Terminal 2 and 2
Each of the two is placed at the patient's bedside. One terminal can be dedicated to the use of a single patient, or it can be used for multiple patients.
Terminals 32 and 34 can be located in a nursing station or a nurse / physician lounge area. Target
The Minal 85 is designed by the system administrator to build and maintain the system, and system status and error
A system console used to provide additional services such as displaying messages, recording messages, and making diagnostics.

Each bedside workstation or terminal, such as terminal 2, has a video display, calculation, and display with a visual screen 3 for displaying information to the observer. A housing 4 containing the data storage and communication equipment and having associated therewith pointing devices such as a keyboard and a mouse 5, and connections 7 and to one or more bedside devices 8 and 10. Including 9. Bedside devices 8 and 10 may take the form of patient monitoring equipment suitable for the patient being treated, such as EKG monitors, respiratory monitors, and the like.
The bedside terminal 22 has a different set of bedside devices 28 and 30 from that connected to the terminal 2.
Can be combined with.

The nursing stations or lounge terminals 32 and 34, and the system console 85, may be the same as those used in the patient care unit, but without the bedside device connections, or they May have slightly different equipment (eg, personal computer) as long as they provide similar functions.

Also coupled to LAN 1 is a file server 62 and associated disk storage device 64. File server 62 has workstations 2, 22, 3
2, 34, and 85 provide controlled access to write information to and read information from the disk storage device 64.

Optionally to LAN1 for coupling various system peripherals to LAN1 (not shown)
Interfaces can be combined. For example, a remote access modem may be coupled to one of such interfaces to provide a remote terminal (not shown) located anywhere in the hospital, such as a hospital or doctor's residence. Access to the system from. Remote access can also be used to diagnose system problems from remote facilities. The laboratory system can be coupled to the interface to allow research information to be communicated between the laboratory system and the clinical management system. An order communication system can be coupled to the interface to allow the order to communicate from the system to other hospital systems (eg, pharmacies or laboratories) and vice versa. A record storage device can be coupled to the interface to securely store any information stored in the system on a suitable recording medium such as a magnetic tape or optical disc.

Printers 81 and 83 are coupled to the file server 62 to print patient information for the convenience of hospital personnel and monitor all observations, orders, parameters, treatment plans, and monitoring. Appropriate legal records of other patient information about the patient can be maintained. Printer 81
And 83 may be any suitable printer, for example a laser printer or a high speed dot matrix printer. The printer can optionally be coupled to the bedside terminal and / or the nursing station or lounge terminal if desired.

In operation, the user of the system, typically a nurse or doctor, uses a keyboard, mouse, or other device to enter information such as a light pen, touch pad, track ball, or the like. Interact with the system by using other suitable means.

An "icon", a screen sensitive area, or the like, or any combination of these suitable for the end application can also be provided. An "icon" is a symbol displayed on the screen whose function is defined for the user by the system in the light of the current screen environment, and these are the user's It can be easily changed according to the direct requirements of the application. In the present invention, the icon is selected by moving the screen cursor with the mouse by the system user and "clicking" on the icon, i.e. pressing the mouse button while the cursor is over the icon. To be done.

The user provides the system with information or questions by keyboard and / or by the indicating device (s), and / or by the information displayed on the screen by the system and / or Or, in another embodiment, the information is received by an audible signal that may also include speech synthesis.

FIG. 3 shows a block diagram of the processing unit associated with the workstation or terminal of the present invention. Each terminal includes processing, storage, and communication functions.

In FIG. 3, the network interface module (NIM) 12 has terminals connected to the LAN.
Interface to 1. The terminal also comprises a processor 14, a random access memory (RAM) 16, and a bus interface circuit 18. In the preferred embodiment of the invention, processor 14 is an MC6803 available from Motorola, Inc.
Type 0. A disk controller 36 is coupled to bus interface 18 via bus 35, and it is connected to disk drive 38 via bus 37.
Is bound to. A graphics controller 44 is coupled to bus interface 18 via bus 43 and to video display unit (VDU) 3 via bus 45. A serial input / output controller 48 is coupled to bus interface 18 via bus 47, and it is coupled to mouse 5 via bus 49 and keyboard 50 via bus 46.

Census Screen FIG. 4 shows the CENSUS information screen, which is presented to the system user upon logon or which can be accessed by the user from other levels of the system hierarchy. As shown, the CENSUS information screen displays 2NTU, 9NBURN, MICU, 9NICU,
And an area 70 listing various wards or rooms in a hospital or clinic, such as a CCU.

In the example shown, the ward 9NBURN
Has been selected, and thus screen area 72 is displaying a list of rooms or beds 201-208. Screen area 74 displays the corresponding patient. Screen area 76 shows the corresponding patient ID number. Screen area 78 can be used to record additional information about any patient.

The user identifies the patient to the patient's name or ID number (if shown on the screen) or room /
It can be selected by pointing or clicking on the bed number (if such room / bed is shown as unoccupied). The latter choice is made to accommodate new patients.

After the patient is selected by the user, the user is provided with some "softkey" options at the bottom 80 of the screen shown in FIG. The "softkey" options are shown in areas 84, 86, and 88, respectively, TRANSFER, DISCHARG.
Includes E and OPEN CHART. The user can then select the desired softkey option by pressing the relevant key on the keyboard or by pointing and clicking with the mouse.

TRANSFER, DISCHARGE,
And in addition to other options, the user
Donald M. Jackson) can be selected and then the OPEN CHART soft key. This results in displaying the default section and the default form associated with the selected patient, for example, as shown in FIG. 6 described below, the user may be directed to the FLOWSHEET section and MEDICATION ADMINISTRATION for this particular patient.
The ON RECORD form will be displayed and shown. The first section and the first form to appear in the list are shown by default. From this point the user can select other sections and forms to view as desired.

Section / Form Hierarchy The automated clinical record management system of the present invention utilizes two levels of section and form organization or hierarchy, which is very similar to a manual patient charting system. . This is the "chart metaphor"
"taphor)". Once a patient is selected from the CENSUS screen, all records associated with that patient are just as they would be if a manual record keeping system were used,
It is organized in a two-level hierarchy that is easy to understand.

Each section includes physician chronological and active orders, organizing of orders into cardex and task lists, nursing assessment, nursing care planning,
Patient records, such as therapy documentation including secretions, drugs, etc., records of observations including variables monitored with study results, and organization of all patient data into flowsheets, graphs, and notes. Offered for all basic categories of records. Since the goal is to provide comprehensive computer-based bedside decision support for medical staff when caring for patients, the number and type of each section and form will necessarily be in-hospital. And it will change depending on the hospital. Sections and forms will also vary according to patient, individual physician, and workstation location.

For example, referring to FIG. 5, screen portion 152 includes a flow sheet (FLOWSHET), an order (ORDERS), a nursing care plan (NURSING).
CARE PLAN: NCP), evaluation (ASSESSS
MENT), LABS, Respiratory Therapy (RESPI)
RATORY THERAPY: R. T. ), And a list of various sections, including KARDEX. In this example, the ORDERS section is selected, which is indicated by "ORDERS" 203 appearing in the video inverted to the user. The two forms under ORDERS are ORD
ER SHEET and ORDER
HISTORY (order history) and is shown in portion 154 of the screen. ORDER SHEE
The T-form has been selected by the user, and this is represented by the inverted video on the screen "O.
RDER SHEET "209.

When building a system for a particular institution, the system builder works with that institution to tailor the task list for each hospital unit. In a given hospital, eg, a cardiology unit, task lists are usually presented in some standard format, whereas in pediatric units task lists may appear in somewhat different formats and with different content.

An important advantage of the present invention is that all parts of the system are linked so that information can be shared between each section and form with a single data entry. For example, once a patient's demographics have been entered for a given patient, they will similarly appear in various forms for that patient. Any correction of demographics for a given patient need only be made once, and it will automatically be applied to any other form for that patient.

[Order Input] FIG. 5 shows ORDERS
ORDERS SHEE in the (Order) section
A T (order sheet) form is shown. The ORDERS
The SHEET form is used to enter the physician's order for the selected patient. There are many types of physician orders, such as medication orders, research orders, radiological orders, consultant orders (eg regarding care that should be provided by other doctors) and nutrition, psychiatric care, etc. Health, etc.

The example just described with respect to FIG. 5 is based on the order of a physician to give the patient a dose of 2 milligrams of Valium to the patient once a day as needed to reduce anxiety. Is. Start date is 19
January 5, 1988 and stop date is January 8, 1988.

After obtaining the appropriate input to the system using the predefined security measures, the physician selects from the list (not shown) the type of order (eg medication) he wishes to enter.

The doctor then moves the cursor 20 from the list 265.
Which drug (eg, valium) by placing 0 on the "valium tablet" display and selecting with the pointing device.
Choose what should be prescribed. This immediately puts the word "valium pill" in the "drug name" screen area 26.
Make it appear in 9.

Next, the doctor enters "root", "dose", "frequency" in the corresponding space of the medication order input pop-up window 263.
Select all other suitable information, such as "number of doses", "start date", and "start time", etc., by directly entering such information or selecting it from the displayed list Meet by doing. the system,
Certain input fields, such as "root", "dose", and "frequency" can be defaulted to values compatible with hospital protocols for a given order.

Some information, such as "order date", "order time", and "order MD", is already known by the system and the default value is automatically shown on the screen display. . The physician can also enter comments in the "Comments" space. After the order is electronically signed by the doctor, it becomes active for that patient.

Once the order is activated, the information based on the order is automatically disseminated to all appropriate forms within the system.

For example, the ORD of the ORDERS section
The same information presented on the ER SHEET form is forwarded by the doctor's signature to the ORDER HISTORY form, which is a chronological list of all orders starting on the patient's acceptance date. further,
Medication order input is also MEDICAL ADMINISTRATION RE in the FLOWSHEET section.
In the CORD form, MED of the KARDEX section
ICAL ADMINISTRATION RECORD
D form and TASK in KARDEX section
Copied as an intervention or caregiver to be performed on the LIST form.

Regarding the drug selection displayed in the screen area 265 of FIG.
If "ride" is selected, the order of the nip ride is K
On the TASK LIST form of the ARDEX section, the medical management of the FLOWSHEET section (MED
ICAL ADMINISTRATION RECORD
D) On the form, I in the FLOWSHEET section
On NTRAVENOUSMEDICATION form (screen example not shown), and FLOW
It will appear on the INTAKE / OUTPUT form in the SHEEET section.

FIG. 6 shows the medical management record form in the FLOWSHEET section. The medical care record form provides and documents information related to drug management. The medical care record form shows the order of medication for the selected patient in the flowsheet format. The medical care record form, when ordered by a physician, is used by a caregiver to record medications given to a patient. Drugs are added to or removed from this form as a result of physician orders. If the medication is not given as ordered, the nurse can indicate this along with the corresponding reason.

As described below, the caregiver can chart the care directly on the caregiver record form itself, or the caregiver can chart the appropriate portion of the caregiver record form via the TASK LIST form pop-up window. can do.

In the left column of the area 156 in FIG. 6, the "Start" and "Stop" dates are displayed.
The "start" and "stop" times along with the corresponding dosing orders are presented.

Dosing orders can be divided into routine dosing orders and PRN (ie, as needed) dosing orders. In the case of PRN orders, the specific symptoms to be treated can be listed (eg severe pain, anxiety, etc.).

All relevant medication order information is given including the medication name (and generic name, if available), "dose", "route / site", and "frequency".

To view information that is part of the selected form but "offscreen", the user must scroll horizontally or vertically by selecting the appropriate scrolling icon (not shown). You can

For orders for valium tablets, dosing order information is provided in screen areas 237 and 239 of FIG. Screen area 237 shows that the first dose of valium was given at 09:00 on January 5th and the last dose of valium was given at 09:00 on January 8th.
It means that it will be done to. Screen area 239
Provides drug name, dose, route / site, frequency, and comments on the administration of Valium to selected patients.

Following the medication order area, "Scheduled time (Sch
scheduled time ”,“ actual time (Actu
al Time ”,“ Dose ”,“ Route / Site ”,“ Comments ”, and“ Ini ”.
“Tials)”. The "scheduled time" column indicates the time when the drug is scheduled to be administered. The nurse indicates the actual time the drug was administered in the "Actual Time" column.

For example, for dosing of valium, screen area 271 shows that the next scheduled dosing of valium is 0.
It shows what should be done at 9:00. The example screen shown in FIG. 6 represents the information at 09:12 on January 7, as shown in the upper right corner. In the screen area 272, the actual time at which valium was administered is shown as 09:11. Screen area 273 shows that the dose was 2 milligrams. Screen area 274 indicates that the root / site is "oral". The brightly illuminated screen area 238 shows the caregiver's initials as "LN" by default, showing the caregiver who administered the valium drug. By signing with the "Sign" softkey 277, the caregiver will see the screen area 23
The default initials shown in 8 can be enabled.

The medical management record form shown in FIG. 6 is 1
The shift, ie the administration of the drug during a 24-hour period, or some other hospital-defined period, can be documented.

Information can be recorded in the medical care record form by one of two methods. That is, as described herein with respect to FIG. 6, directly by appropriate entry of information into the medical care record form, or FIG.
Can be recorded through a window to the TASK LIST form, as described below with reference to (a) through (c). If the nurse charts directly to the medical management record form, TASK LIS
Corresponding forms, including T-forms, are automatically updated.

To enter information for an item directly into the medical care record form, the caregiver first selects the desired field for entry. The nurse can then change the actual default time and confirm the dose, route, and make any relevant comments if the drug is given at a different time than the scheduled time. . When the entry is complete, the nurse signs the record. When signing the record, the nurse's proper initials will appear on the form.

This information is distributed to all corresponding forms, and the 09:00 entry in the task list is automatically removed. The input is optionally a tax list (eg, TAS) indicating that all tasks have been completed.
K LIST HISTORY form (not shown) can be shown on the corresponding form.

CREATING A TASK LIST With respect to the task list itself, FIG. 7 shows an information screen showing the first page of the TASK LIST form in the KARDEX section.

The task list is a time-based list of all actions or care to be performed during a given shift (or other defined period) as a result of the doctor's order and the caregiver's order. is there.

The task list is automatically generated as a result of physician and caregiver orders. Task list is O
ORDERS SHEE in the RDERS section
From T form or NURSING CARE PL
Automatically populate orders entered from any of several forms in the AN section.

By capturing the contents of the order at its source, the system of the present invention eliminates the need for a nurse or other hospital staff to manually transcribe relevant information from one form to another. In addition, all actions taken by the user in charting items from the task list are documented in an appropriate form for later retrieval.

With particular reference to FIG. 7, the task list screen comprises an area 156 listing each action or care to be performed on the selected patient in a chronological sequence. For example, one of the actions to be taken at 09:00 is to administer 2 milligrams of valium tablets for anxiety or insomnia, if necessary.

[Chartization from Task List] FIGS. 8A to 8C are for explaining how the system user can chart from the task list corresponding to the selected patient. 3 shows various information screens.

The user can chart directly without leaving the task list by selecting an item on the task list and recording an indication that some appropriate action will be taken regarding it. A window is opened in the appropriate part of the underlying form, while at the same time displaying the appropriate part of the task list. The action is then recorded on the underlying form and also automatically all other suitable forms (eg, FLOWSHEET section, NURSING CARE PLAN section,
The other form) is copied and transferred.

Referring now specifically to FIG. 8 (a), the user moves the arrow 200 of the cursor adjacent to the desired item and selects by the pointing device 5 (see FIG. 2) the barium. Administration at 09:00 is selected. Area 256 is then illuminated brightly, as shown in FIG. 8 (a), and a "CHART" softkey 258 appears at the bottom of the display.

The user then selects the "CHART" softkey 258 to indicate that he or she is ready for charting. As shown in FIG. 8B,
This is FLOW SHEEET related to charting of medication
The section's medical records form (shown in Figure 6) and specifically the lines relating to the order of the valium (ro
w) Pop-up window 2 for 252 (Fig. 6)
Open 59. The information displayed in the pop-up window 259 (see FIG. 8B) is FLOWSHE.
Line 2 of the medical management record form in the ET section (Figure 6)
The same as that found in 52.

The actual medical management record form is TASK
A pop-up window to the medical care record form filled in by the LIST form, with the former displaying both charted and future charting times, while the latter only displays the current charting time. In some respects, it's a little different.

Still referring to FIG. 8B, the nurse then pops up a pop-up displaying the appropriate care or procedure.
Directly chart to pop-up window 259 by selecting an area within window 259.

The caregiver can then document the correct time the medication was given by moving the cursor 200 to the “Actual Time” field 260 and pressing the select button on the pointing device 5. Field 260 becomes bright and shining, and the nurse, if desired,
You can change the default time by making the appropriate keyboard entries.

The caregiver will then check the dosages and sites shown, can change if necessary, enter a comment if desired, and then enter "O".
It can be activated by selecting the K "softkey 278. This will pop up window 259.
To disappear. The information about the 09:00 Baileum dose will appear bright and shiny to reflect the charting effect. When the nurse signs on all unsigned charts on the form by selecting the "Sign" softkey 279, the screen changes to that shown in Figure 8 (c). FIG. 8 (c)
The screen shown in Figure 2 reflects that a 09:00 valium dose was given, as this care is no longer seen on this form.

As each item is charted (and signed) from the task list, it is removed from the user's view. However, any care or procedure not performed during that shift will be maintained on the task list for the next shift or the next 24 hour period.

As each item on the task list is charted, the corresponding item on the appropriate form (s) is also automatically charted.

This can be seen from FIG. 9, which is F
9 shows a medical management record form in the LOWSHEET section. Areas 272-275 have just been updated in this form due to the task list charting behavior described above.

The contents of row entry 252 are the same as those shown in row 259 of the example task list shown in FIG. 8 (b) and 2 milligrams of valium dose, 09:
Scheduled time of 00, actual time of 09:11, dose and route.

In general, charting from the task list can be accomplished by some care or procedure displayed on the TASK LIST form. While the user is charting directly to the appropriate form via a popup window on the task list, the user
Stay within the SK LIST form environment. Charting within the task list provides a great advantage because the user does not have to leave the task list to chart on other forms in the system.

Charting Directly From Form In the example shown and described above, the user TASK
Charted on the FLOW SHEEET section medical care record form via the LIST form.
As previously indicated, the user may also choose to chart directly on the appropriate form in the system, such as a medical care record form.

In addition, charting changes made to the FLOWSHEET section health care record form, either directly or through the TASK LIST form window, are automatically displayed on all other suitable forms in the system. .

For example, the nurse takes the time 07:00 at 06:
100 cc of D5 starting at 00 scheduled time
Assuming that a 500 milligram dose of ampicillin infusion given in W solution was charted, and the nurse directly charted this on the "Drips IV'S" portion of the FLOWSHEET section medical care record form. Suppose that. In that case, this charting action is K
On the TASK LIST form of the ARDEX section, the INTRAVEN of the FLOWSHEET section
It will be recorded automatically as charted on the OUS MEDICATION form (screen example not shown) and on the INTAKE / OUTPUT form in the FLOWSHEET section.

This is shown in FIG. 10, which shows F
INTAKE / OUTP of LOWSHEET section
The UT form is shown. INTAKE / OUTPUT
The T-form shows the charting time in hours at the top of the form, and it shows "INTAKE", "TOTAL INTAKE", along the left side of the chart.
"OUTPUT", "TOTAL OUTPUT",
"NET I / O", and "ACCUMULATIV
E I / O "is shown.

Under the "INTAKE" heading, Nipride and Ampicillin IV's are shown by rows 346 and 347, respectively. Nipride infusion is an infusion at a rate of 10 cc / hour.
The volume of 10 cc infused during the previous hour is charted by the nurse at the end of each hourly period. Therefore, it appears under the 07:00 heading 10
cc represents that administered from 06:00.

The ampicillin order is for 500 milligrams to be administered with 100 cc D5W (5% dextrose in water) every 6 hours starting at 06:00. This task will appear on the TASK LIST form (Figure 7) in the same format as shown for the 12:00 and 18:00 administrations of ampicillin.

Referring now to FIG. 6, assume that the nurse began administration of ampicillin at 6:00. Ampicillin I. V. When the administration of is completed (assuming 06:15), the caregiver will chart completion and sign the form with completion time (06:15). Next, 06:00 administration of ampicillin was given to TASK LI.
Will be removed from the ST foam.

Further, under the 07:00 hour column of the INTAKE / OUTPUT form (see FIG. 10), the uptake and discharge of all fluids, in this case during the previous hour, is summarized, but the ampicillin The uptake of 100 cc of the fluid component that occurs during the administration of will be recorded, as indicated by reference numeral 356 in FIG.

TOTAL INTAK at line 354
E is the sum of infusions from Nipride infusion and any ampicillin dosing. At 07:00 hours, T
OTAL INTAKE is shown as 110 cc.

OUTPUT (reference numeral 349) contains urine and nose / stomach (NG) headings, and 07:
00, TOTAL OUTPUT (reference number 3
50) is shown as being 65 cc.

NET I / O (reference numeral 351) is TO
TAL INTAKE and TOTAL OUTPUT
, Which in this case is 45 cc. CU
MULATIVE I / O (reference number 355) indicates the change in INTAKE or OUTPUT over the day. Assuming that the CUMULATIVE I / O was -100cc at 06:00, 07:00
If the NET I / O in is 45 cc, 07: 0
CUMULATIVE I / O at 0 is (-100
cc) +45 cc, which is equal to -55 cc.

Therefore, in summary, 0 of ampicillin
Direct charting of the 6:00 administration to the medical care record form is automatically (by removal of this task) TASK
LIST foam and INTAKE / OUTPUT (by recording 100 cc of fluid uptake)
Recorded on both forms.

[Description of Attached Documents] Attached Documents, Part I,
Is a pseudo code of software (pseudo) for generating a task list from at least one order input.
-Code) outline. In the indicated case, the order is the physician's order as described above for the administration of Valium.

Part II gives an outline of the software for charting users from the task list, opens a window in the appropriate underlying form, enters information about the accomplishment of the task in such form, and Including closing such a window.

It will be appreciated by those skilled in the art that the disclosed invention may be modified in various ways and, in particular, may take many embodiments other than the preferred form described and illustrated above.

For example, the content, selection and number of task lists can be determined to suit the particular needs of the system user. Also, the particular hardware system in which the patient record keeping system is implemented is optional.
Moreover, the number of workstations that can be connected to the network is arbitrary and depends on the user's application.

Accordingly, the appended claims are intended to cover all modifications of this invention that are within the true spirit and scope of this invention.

[Appendix]

Part 1. Generation of task list from order input 1. Select patient. A. Display patient census screen. i. "Room / Bet", "Patient Name", "Patient ID",
And "acceptance date" are displayed ii. 1. For each patient on the list A. i. Repeat. B. Select patient. i. Select the patient by placing the cursor over any part of the "Patient Name" field and pressing the select button. ii. The selected patient name is highlighted. iii. Display "Transfer", "Discharge", and "Open Chart" softkeys. 2. Select the "Open Chart" softkey. A. Select the "Open Chart" softkey by placing the cursor over the "Open Chart" softkey and pressing the select button. B. Open patient file by reading from selected patient database. 3. View sections and forms for selected patients. A. Section: "ORDERS" and Form:
Display "ORDER SHEET". B. Form: Display "ORDER SHEEET" by displaying a kind of "active order". C. Display the "New Order" softkey. 4. Select the "New Order" softkey. A. Select the "New Order" softkey by placing the cursor on the "New Order" softkey and pressing the Select button. B. Display a pop-up window with an input field named "Select Order Input Type". C. Display a popup window with a list of order types. D. Select the order type “MEDS”. E. Display the pop-up window for "Medication order entry". i. Display the label "Medication order entry". ii. Editable fields "order date", "order time", "order MD", "drug name", "route", "dose", "frequency", "number of doses", "start date", Display "start time", "stop date", "stop time", and "comment". iii. "Order date" is the current date, "Order time" is the current time, "Order MD" is the initials of the logged on doctor, "Start date" is the current date,
Then, the "start time" is defaulted to the current time. iv. The "drug name" input field is selected by placing the cursor over the "drug name" input field and pressing the select button to highlight the "drug name" input field. a. Display an additional pop-up window with the medication list. b. Select the drug "Baylium tablets" by placing the cursor over the "Valium tablets" field and pressing the select button. c. Close the drug list pop-up window. d. Display "valium tablet" in the "Drug name" input field in the medication order input pop-up window. v. Default the most common "route", "dose", and "frequency" based on hospital or unit procedures. vi. Edit the "dose". a. Select the "Dose" field by placing the cursor on the "Dose" field and pressing the select button. b. Correct the "dose" entry by keyboard entry. vii. 4. E. ii. 3. For other editable fields listed in. E. vi. Repeat. viii. Select the Comment field and enter the appropriate comment. ix. Select "OK". x. Check for required fields and edits (eg, "Dose Count" field has valid entries, "Dose" is appropriate with edit request for field). xi. Close the medication order input popup window. xii. Form: "ORDER SHEET" to "M
Display with update showing new order under the heading "EDS." 5. Sign the order A. Select the "Sign" softkey by placing the cursor over the "Sign" softkey and pressing the Select button. To do. B. Check database for consistency (eg duplicate orders). C. Accept the "sign" of the order. 6. Develop the schedule (ie, display frequency of dosing based on frequency and hospital policy). A. Develop a schedule for shifts and days based on hospital / unit policy. 7. Fans out information from the order depending on the selection of the "Sign" softkey. A. Information Section: FLOWSHEET, Form: MEDICAL ADMINISTRATION R
Copy forward to ECORD. i. "Drug name", "route / site", "dose",
Copy-forward "frequency", "start / stop time", "scheduled time", "actual time", "comments", and "initials" to the appropriate location on the screen. B. Information section: KARDEX, form: TA
Copy forward to SK LIST. i. Copy-forward and chronologically insert the dosing frequency into the schedule for a given shift or day. ii. "Drug name", "dose", "route / site",
Copy-forward "frequency" and "comment". 8. A chronological sort of tasks related to orders. A. Break down the order into a set of time-based tasks. B. Sort all tasks by date. C. Sort all tasks by time for each date. Part II. Charting from task list 1. Section: Select "KARDEX". A. Place the cursor on the "KARDEX" display and press the select button to select the section: "KARDEX"
Select. B. Form: Display "TASK LIST". 2. Select the care or intervention that should be charted. A. Place the cursor on the task to be charted from the task list and press the select button. B. Highlight the task description. C. Display the "Chart", "Non-time", and "Adjust" softkeys. 3. Select the "Chart" softkey. A. Place the cursor on the "Chart" softkey and press the select button. B. MEDICAL ADMINISTRATION RE as a pop-up window on the task list
Display part of CORD form. i. "Start / stop time", "drug name" entered in the medication order input pop-up window,
Order “dose”, order “route / site”, “frequency”, “scheduled time”, “actual time”, charted “dose”, charted “route / site”,
"Comment" and "Initial" are displayed. ii. The "initial" is defaulted to the ID of the logged-on user. C. Default "actual time" to "scheduled time" or current time and display "actual time". D. Default and display charted "dose" to ordered "dose". E. Default and display charted "routes / sites" to ordered "routes / sites". 4. Edit "actual time", charted "dose", charted "route / site", and "comments". A. Select the "Actual Time" field by placing the cursor over the "Actual Time" field and pressing the select button. B. Enter the medication time. C. Similarly, edit the charted "dose", charted "route / site", and "comments". 5. Confirm by selecting the "OK" softkey. A. Place the cursor on the "OK" softkey and press the select button to accept the input. B. Pop-up window with MEDICAL AD
MINISTRATION RECORD Close in foam. C. Highlight charted tasks on the task list. 6. Select the "Sign" softkey. A. Place the cursor on the "Sign" softkey and press the select button. B. Remove charted tasks from the task list. 7. MEDICAL ADMINISTRATOR of information
Fan out to the ON RECORD form and other forms on the "Sign". A. The entered "actual time", charted "dose", charted "route / site", and "comment" are added to the MEDICAL ADMININISTRA
Copy forward to TION RECORD form.

[Brief description of drawings]

FIG. 1 is a block diagram generally illustrating a patient care process in a typical hospital environment.

FIG. 2 is a block diagram showing a preferred embodiment of a data processing system incorporating an automated clinical record system according to the present invention.

FIG. 3 is a block diagram illustrating a processing unit associated with a workstation or terminal according to the present invention.

FIG. 4 is an explanatory diagram showing a CENSUS information screen.

FIG. 5: ORDERS in ORDERS section
It is explanatory drawing which shows a SHEEET form.

FIG. 6 is an explanatory diagram showing a medical management record form in a FLOW SHEEET section.

FIG. 7: TASK L in KARDEX section
It is an explanatory view showing an IST form.

FIG. 8 is an illustration of an information screen showing how each item can be charted directly from the task list without leaving the task list environment.

FIG. 9 is an explanatory diagram showing an updated medical management record form in a FLOW SHEEET section.

FIG. 10 IN in FLOW SHEEET section
It is an explanatory view showing a TAKE / OUTPUT form.

[Explanation of symbols]

 1 Local Area Network 2, 22, 32, 34, 85 Workstation 3 Screen 4 Housing 5 Mouse 8, 10, 28, 30 Bed Site Device 62 File Server 64 Disk Storage 81, 83 Printer 12 Network Interface Module 14 Processor 16 random access memory 18 bus interface circuit 36 disk controller 38 disk drive 44 graphics controller 48 serial I / O controller 50 keyboard

─────────────────────────────────────────────────── ───

[Procedure amendment]

[Submission date] September 10, 1993

[Procedure Amendment 1]

[Document name to be amended] Statement

[Name of item to be corrected] Brief description of the drawing

[Correction method] Change

[Correction content]

[Brief description of drawings]

FIG. 1 is a block diagram generally illustrating a patient care process in a typical hospital environment.

FIG. 2 is a block diagram showing a preferred embodiment of a data processing system incorporating an automated clinical record system according to the present invention.

FIG. 3 is a block diagram illustrating a processing unit associated with a workstation or terminal according to the present invention.

FIG. 4 is an explanatory diagram showing a CENSUS information screen.

FIG. 5: ORDERS in ORDERS section
It is explanatory drawing which shows a SHEEET form.

FIG. 6 is an explanatory diagram showing a medical management record form in a FLOW SHEEET section.

FIG. 7: TASK L in KARDEX section
It is an explanatory view showing an IST form.

FIG. 8 is an illustration of an information screen showing how each item can be charted directly from the task list without leaving the task list environment.

FIG. 9 is an illustration of an information screen showing how each item can be charted directly from the task list without leaving the task list environment.

FIG. 10 is an illustration of an information screen showing how each item can be charted directly from the task list without leaving the task list environment.

FIG. 11 is an explanatory diagram showing an updated medical management record form in the FLOW SHEEET section.

FIG. 12 IN in the FLOWSHEET section
It is an explanatory view showing a TAKE / OUTPUT form.

[Explanation of Codes] 1 local area network 2, 22, 32, 34, 85 workstation 3 screen 4 housing 5 mouse 8, 10, 28, 30 bed site device 62 file server 64 disk storage device 81, 83 printer 12 network 12 Interface module 14 Processor 16 Random access memory 18 Bus interface circuit 36 Disk controller 38 Disk drive 44 Graphics controller 48 Serial I / O controller 50 Keyboard 21 Port A 22 Port B 24 Charge pump and bias unit 26 Reference MUX 28 Channel MUX 30 Bus 32 External trigger circuit 34 I / O circuit 36 Port B input circuit 38 Address decode circuit 40, 4 Sample-and-hold circuit 44 MUX 46 Sample timer 48 Periodic timer 50 RC oscillator and prescaler 52 Capacitive D / A converter (CDAC) 54 Dummy CDAC 56 Comparator 58 Successive approximation register 60 Control register and logic circuit 62 CCW table 64 result table 66 address decode circuit 68 data format circuit 70 bus interface unit 72 inter-module bus

[Procedure Amendment 2]

[Document name to be corrected] Drawing

[Correction target item name] All drawings

[Correction method] Change

[Correction content]

[Figure 3]

[Figure 1]

[Fig. 2]

[Figure 4]

[Figure 5]

[Figure 6]

[Figure 7]

[Figure 8]

[Figure 9]

[Figure 10]

FIG. 11

[Fig. 12]

 ─────────────────────────────────────────────────── ─── Continued Front Page (72) Inventor Oscar Earl Diaz Arizona, Arizona 85021, Phoenix, West Harmont Drive 1702 (72) Inventor Ronald E. Paul 85202, Arizona, USA South Mesa Longmore 2050 (72) Inventor Michael M. Stern 02194 Massachusetts, USA, Lindham Avenue, Needham 184 (72) Inventor Sandra El Stewart Arizona, USA 85044, Phoenix, Wakial Loop 13201 # 3114

Claims (3)

[Claims] 1. A processing unit, a memory unit, and at least one terminal unit, said terminal unit for displaying patient information to a user of the terminal and said user of said terminal displaying said patient information. A method of generating and implementing an integrated plan of care for a patient in a medical information system including input means for entering a system and providing commands to the system, comprising: (a) displaying the Displaying a first form on the means, (b) using the input means, providing an order on a medically relevant task in the form of an action or intervention to be performed on the patient on the first form. Entering, the order providing medical care to the patient, such as a doctor or a caregiver. Input by a responsible person, (c) automatically transcribing information related to the task into a second form as a result of the order, the second form relating to the patient. Comprising a list of related tasks to be performed and including an area for recording a corresponding indication that said task was actually performed by a person responsible for performing said task, (d) said task Automatically and substantially instantaneously transcribing the relevant information into a third form, said third form comprising a list of all tasks to be performed on said patient, said second form In the form of, and further ordered or ordered to the patient as a result of a doctor's order or a caregiver's order. Including all other actions and interventions to be done, (e) displaying the third form on the display means to the human being responsible for performing the task, (f) using the input means Selecting at least one of the tasks from the third form; (g) displaying at least a portion of the second form on the display means to the person including the information and responsible for performing the task. While simultaneously displaying at least a portion of the third form containing the task, (h) using the input means to enter an indication that the task has been performed on the second form. And (i) automatically and substantially instantaneously changing the third form to reflect that the task has been performed. How to integrate planning and generates and implementation of care for. 2. A processing unit, a memory unit, and at least one terminal unit, said terminal unit for displaying patient information to a user of the terminal and said user of said terminal displaying said patient information. A method of generating and implementing an integrated plan of care for a patient in a medical information system including input means for entering a system and providing commands to the system, comprising: (a) displaying the Displaying a first form on the means, (b) using the input means, a first medically relevant task in the form of an action or intervention to be performed on the patient on the first form. Inputting a first order relating to the patient to the patient, such as a doctor or a caregiver. Input by a person responsible for providing personalized care, (c) automatically transcribing information related to the first task into a second form as a result of the first order. Wherein the second form comprises a first list of related tasks to be performed on the patient and provides a corresponding indication that the tasks were actually performed by the person responsible for performing the tasks. Including an area for recording, (d) automatically and substantially instantaneously transferring information relating to the first task to a third form, the third form comprising: Comprising a list of all tasks to be performed on the patient, including the relevant tasks of the second form, and further as a result of a doctor's order or a nurse's order. Including all other actions and interventions ordered or to be ordered for the patient, (e) using the input means to provide a second medical treatment in the form of actions or interventions to be performed on the patient. Entering a second order on the first form for the task involved, the second order being entered by the person responsible for providing medical care to the patient. (F) as a result of the second order, automatically transcribing information related to the second task into a fourth form, the fourth form being performed on the patient. For recording by the human being responsible for performing the task a second list of tasks involved and a corresponding indication that the task was actually performed (G) automatically and substantially instantaneously transferring information relating to the second task to the third form; (h) the third on the display means. Displaying a form to the person responsible for performing the task; (i) using the input means to select the first task from the third form; (j) providing the information Displaying at least a portion of the second form on the display means to the human being responsible for performing the task, while at the same time displaying at least a portion of the third form including the first task. (K) using the input means, inputting an indication that the first task has been performed on the second form, (l) having performed the first task To reflect the above Automatically and substantially instantaneously changing a third form, (m) using the input means to select the second task from the third form, (n) the information And displaying at least a portion of the fourth form on the display means to the person who is responsible for performing the task, while simultaneously displaying at least a portion of the third form that includes the second task. Displaying, (o) using the input means, inputting an indication on the fourth form that the second task has been performed, (p) performing the second task Automatically and substantially instantaneously modifying the third form to reflect that. A method of generating and implementing an integrated care plan for a patient. 3. A processing unit, a memory unit, and at least one terminal unit, said terminal unit for displaying patient information to a user of the terminal and said user of said terminal displaying said patient information. A method of generating and implementing an integrated plan of care for a patient in a medical information system including input means for entering a system and providing commands to the system, comprising: (a) displaying the Displaying a first form on the means, (b) using the input means, providing an order on a medically relevant task in the form of an action or intervention to be performed on the patient on the first form. Entering, the order providing medical care to the patient, such as a doctor or a caregiver. Input by a responsible person, (c) automatically transcribing information related to the task into a second form as a result of the order, the second form relating to the patient. Comprising a list of related tasks to be performed and including an area for recording a corresponding indication that said task was actually performed by a person responsible for performing said task, (d) said task Automatically and substantially instantaneously transcribing the relevant information into a third form, said third form comprising a list of all tasks to be performed on said patient, said second form In the form of, and further ordered or ordered to the patient as a result of a doctor's order or a caregiver's order. Including all other actions and interventions to be done, (e) displaying the third form on the display means to the human being responsible for performing the task, (f) using the input means Selecting at least one of the tasks from the third form; (g) displaying at least a portion of the second form on the display means to the person including the information and responsible for performing the task. While simultaneously displaying at least a portion of the third form containing the task, (h) using the input means to enter an indication that the task has been performed on the second form. (I) modifying the third form automatically and substantially instantaneously to reflect that the task was performed, and (j) relating to completion of the task. Automatically fourth of that information
A method of generating and implementing an integrated care plan for a patient, the fourth form comprising a list of information about the patient. .