Patent ID: 6289316
Filing Date: 2001-09-11
Classification: G06Q,G16H,Y10S

Abstract:
A computer implemented method of creating a Progress Note (PN) for a patient medical chart in a Clinical Information System (CIS) comprising the steps of:defining a PN data structure modeled as a sequence of blocks, the order and sequence being controlled by authors and an accountability model, every block being assigned a chart-specific note identifier and a note-specific sequence position;accessing from a CIS database a patient chart and displaying a PN index containing attributes including dates, diagnoses, authors, and procedures;prompting a care giver to make a selection from the displayed PN index and, in response to a selection, displaying a PN Window containing a PN Notebook, each page of the PN Notebook being a Progress Note for the patient;receiving input in the PN Notebook which documents subjective (S) information, objective (O) data, an assessment (A), and a treatment plan (P);storing the SOAP information entered by an author in the CIS database;preventing alteration of a Progress Note in a medical chart stored in the CIS database;optionally permitting a care giver to create a revised version of a Progress Note in a medical chart stored in the CIS database;prompting an author of a Progress Note to sign the Progress Note; andverifying the author's signature before storing the SOAP information in the CIS database,wherein the author is given options of ""Sign"" and ""Initial"" when prompted to sign the Progress Note, selection of ""Initial"" preventing rearrangement above the initialing point and the selection of ""Sign"" preventing both rearrangement and insertion above a signature point.2.The computer implemented method of claim 1 wherein each transaction in a Clinical Information System (CIS) database is associated with a unique Progress Note (PN) in which a context of the transaction is documented, further comprising the steps of:prompting a caregiver to select a transaction for which a PN context is desired;displaying the PN associated with the selected transaction; anddesignating a section of the PN in which the selected transaction is documented.