Creating and using protocols to create and review a patient chart

A method and apparatus for creating and using a reusable medical protocol to create a patient chart is provided. The protocol is created by selecting various medical findings from a database containing a plurality of coded medical findings, wherein the coded medical findings are grouped into several different sections such as a symptoms section, a history section, a physical findings section, a diagnoses section, a test section and a therapy section. Once the medical findings have been selected, the order of the display of the findings within the protocol is selected. The created protocol is then displayed on a display screen. The healthcare professional then selects medical findings displayed in the protocol which describe the patient's situation. According to the present, the selected medical findings are automatically placed in the correct section of the patient chart based upon the code of the selected medical finding, wherein the patient chart is divided into the same sections as the protocol.

FIELD OF THE INVENTION 
The present invention relates to a method and apparatus for creating 
patient charts by healthcare professionals, and more particularly to a 
method and apparatus for creating and using medical protocols to create 
and review patient charts. 
BACKGROUND OF THE INVENTION 
While many aspects of the operation and administration at hospitals and 
other healthcare facilities have been computerized over the past years, 
one of the most important aspects, the generation of patient charts, the 
updating of these charts, the review of the chart, and the generation of 
care plans by healthcare professionals such as doctors, nurses, 
therapists, and the like, is still performed largely by hand. As a result, 
while a patient chart of some type is normally generated shortly after a 
patient is admitted to the healthcare facility for a particular service, 
for example, an intensive care unit, cardiac surgery unit, or the like, 
the chart may not always be updated to reflect actual progress by the 
patient. 
When a patient comes into a health care facility, the patient may have 
numerous related or unrelated problems that the healthcare provider will 
have to sort through when determining what is wrong with the patient and 
what treatments should be prescribed for the patient. Manually reviewing 
the chart for previous clinical findings relevant to the current problems 
can be a very time consuming and errorprone procedure. The diagnostic step 
in the treatment of the patient can thus be a very difficult process and 
arguably the most important step in treating a patient. Today, most 
healthcare professionals must rely on their memory and experience as well 
as written materials when making a diagnosis. Unfortunately, all of the 
needed materials may not be available during the examination of the 
patient and thus important questions may not be asked or tests performed 
which could help the healthcare professional in determining the correct 
diagnosis for the problems being experienced by the patient. Thus, it 
would be advantageous to allow healthcare professionals to create medical 
protocols which prompt the healthcare professional with lists of questions 
that should be asked, symptoms to look for, and tests that should be run, 
during the examination process. 
Even after a diagnosis has been made and a care plan has been devised, the 
patient chart may not be referred to when the healthcare professional is 
preparing progress notes on the patient. Thus, there is no check to assure 
that the original treatments have in fact been followed, or that proposed 
resolution dates in the chart have been met or updated. When changes in 
the chart are made as a result of changes in the status of a patient, such 
changes are frequently not entered in the original chart. Thus, good 
archival records are not generally maintained for changes in treatment. 
The professional notes for a particular patient frequently do not include 
an updated version of the patient's chart. Further, even though a form may 
be available for progress notes, the form does not take into account the 
unique problems of the individual patient, and does not give the 
healthcare professional a checklist of items to be investigated for such 
problems or suggested interventions or resolution dates for the particular 
patient problem. When changes are made or expected outcomes are not 
achieved, the reasons for such occurrences are seldom provided, making any 
further review far more difficult. Again, a good archival record of what 
has been done for the particular patient is not readily available. Because 
of the absence of good archival records, and the absence of reasons for 
changes or deviations, tracking a problem for quality control, legal or 
other reasons is difficult, and it is difficult to research the relative 
effectiveness of various interventions or to perform other research from 
the records. 
The lack of a complete archival record can also cause significant problems 
for healthcare professionals who must adequately document the examination 
and treatment of patients whose medical bills are being paid by insurance 
companies. If the healthcare professional does not provide proper 
documentation, the insurance companies will not pay the bills. 
Furthermore, healthcare professionals have less time to spend with each 
patient these days. As a result, the healthcare professional does not have 
time to determine from the original chart and the added progress notes, if 
they are available, the previous problems of the patient and what 
treatments were prescribed. Thus, the healthcare professional needs to 
have an easy way to review charts for each patient. 
Even with computer based patient chart and/or progress note systems, many 
of the problems indicated above still exist. Such systems also in many 
instances lack flexibility so as to be configurable by the healthcare 
professional so as to provide specific help in determining diagnoses and 
for prompting the healthcare professional with lists of symptoms, 
questions which should be asked and tests that should be performed in 
certain circumstances. In addition, they frequently do not give the 
healthcare professional the ability to add special instructions or to add 
items as required. Further, it is generally not possible to obtain either 
an updated chart or historical chart upon request. Thus, there is a need 
for a computer based medical system which enhances the diagnostic 
capabilities of a healthcare provider, provides initial patient charts as 
well as updated or historical care plans. 
SUMMARY OF THE INVENTION 
In a patient encounter a physician/healthcare professional will typically 
ask the patient a series of questions. If the patient has had previous 
encounters, the healthcare professional will want to review the previous 
charts for the patient before the next encounter. Next, the healthcare 
professional will examine the patient, make an assessment of any problems 
which may be present, and perhaps order a series of tests to confirm the 
diagnosis. If a computer-based chart is to be used, a mechanism to 
facilitate the entry of the information is important. It is an object of 
the present invention to provide such a mechanism which is easy to create 
and flexible to use. 
According to one embodiment of the present invention, a method and 
apparatus for creating and using a reusable medical protocol to create a 
patient chart is disclosed. The protocol is created by selecting various 
medical findings from a database containing a plurality of coded medical 
findings, wherein the coded medical findings are grouped into several 
different sections such as a symptoms section, a history section, a 
physical findings section, a diagnoses section, a test section and a 
therapy section. Once the medical findings have been selected, the order 
of the display of the findings within the protocol is selected. The 
created protocol is then displayed on a display screen. The healthcare 
professional then selects medical findings displayed in the protocol which 
describe the patient's situation. According to the present application, 
the selected medical findings are automatically placed in the correct 
section of the patient chart based upon the code of the selected medical 
finding, wherein the patient chart is divided into the same sections as 
the protocol.

DESCRIPTION OF THE PREFERRED EMBODIMENTS 
The present invention uses a computer based medical system to allow a 
healthcare professional to chart the progress of a particular patient. A 
block diagram of the computer based medical system suitable for use in 
practicing the teachings of the present invention is illustrated in FIG. 
1. The medical system 10 contains a processor 16 with one or more input 
devices such as a keyboard 18. The processor 16 also has a database file 
or memory 20 and a knowledge base file or memory 22. The processor 16 
operates a standard display controller 14 which in turn, controls a 
display device 12 at the work station. The display device 12 can be any 
standard type of display monitor, attached or wireless. Furthermore, the 
apparatus 10 can be networked to other such medical systems not 
illustrated which can be placed around a hospital or healthcare facility. 
This allows multiple people to use the medical system for the same or for 
multiple patients. 
The present invention is based upon on medical findings. Medical findings 
are defined as symptoms, history, physical findings, diagnoses, tests, and 
therapy which may be present for a particular patient. The database file 
20 contains over 50,000 such medical findings which are divided into 
categories such as symptoms, history, physical findings, diagnoses, tests, 
and therapy. Furthermore, the descriptions of the medical findings stored 
in the database file 20 are hierarchical and can have up to eight levels 
of description. The first level gives the simplest explanation of a 
medical finding, for example, a cough. The explanations become more 
detailed the lower the level. As noted above, a first level finding may be 
a cough, while a second level finding may be a brassy cough. Another 
feature of the database memory 20 is that all of the medical findings are 
coded so as to be distinct from each other. For example, each medical 
finding can be assigned an internal number which uniquely identifies that 
particular medical finding. In addition, each medical finding also 
contains a code which indicates which category within the database file 20 
the medical finding is associated with. For example, a medical finding may 
contain the code SYM to indicate that the medical finding is associated 
with the symptom section; HIS to indicate that the medical finding is 
associated with the history section; PHY to indicate that the medical 
finding is associated with the physical section; DIS to indicate that the 
medical finding is associated with the diagnoses section; TST to indicate 
that the medical finding is associated with the test section; and RX to 
indicate that the medical finding is associated with the therapy section. 
As noted above, the medical system 10 also contains a knowledge base file 
22. The knowledge base file contains a detailed description of over 2,000 
diagnoses. The detailed description of the diagnoses uses the medical 
finding terms which are stored in the database file 20. For each 
diagnosis, each medical finding associated with the diagnosis is assigned 
a numerical value depending on how important such a medical finding may be 
to the diagnosis. For example, in the detailed description of the 
diagnosis for coronary artery stenosis, medical findings such as chest 
pain or discomfort and dyspnea (shortness of breath), which are strong 
showings of coronary artery stenosis, will be given high values while a 
lack of a desire for food may not be described in the diagnoses at all or 
given a very low value. In one embodiment of the present invention, 
medical findings are assigned values between 1 and 20 wherein the value 20 
indicates the most important medical finding, however the invention is not 
limited thereto. Thus, the values assigned to each medical finding within 
the detailed description are proportional to how important such a medical 
finding is to the diagnosis. Furthermore, the values can vary for a given 
medical finding depending on a plurality of factors such as age of the 
patient and timeframe, i.e., when a symptom occurred in relation to other 
symptoms. For example, a white blood cell count of 18,000 may be given a 
high value if the patient is an adult while the same medical finding is 
not given a value at all if the patient is a new-born child because this 
is normal for a new-born child. 
Here again, the medical findings used in the detailed descriptions of the 
diagnoses are all coded. In addition, over 400,000 links are provided 
between the database file 20 and the knowledge base file 22. In other 
words, the findings in the database file 20 occur over 400,000 times in 
the knowledge base file 22. 
The detailed description of the diagnoses stored in the knowledge base file 
22 contains lists of symptoms as well as personal and family history and 
physical findings which a patient should or may have experienced. In 
addition, the detailed diagnoses contain lists of tests, possible 
therapies, and medications which should be prescribed for the patient if 
the healthcare professional decides that the patient is experiencing a 
particular illness or problem. 
According to one embodiment of the present invention, a method and 
apparatus for creating and using reusable medical protocols to create 
patient charts is disclosed. The clinical protocols are a structured 
combination of coded medical phrases selected from a structured medical 
database of coded phrases and are presented in the order of appearance 
selected by the healthcare professional. The healthcare professional can 
create a patient chart by selecting the desired phrases from the clinical 
protocol reflecting the responses from the patient to his/her questions or 
results from his/her examination, assessment, or other pertinent 
information the healthcare professional wishes to enter. Since the phrases 
are coded, upon selection of the phrases from the clinical protocol, the 
entered information is automatically structured in the chart in the same 
format as the format used in the medical database used to build the 
protocols. That is, symptoms automatically go into the symptoms section, 
physical findings into the physical examination section, diagnosis into 
the assessment section, etc. Since the healthcare professional who builds 
the clinical protocols can put in any combination of coded medical finding 
phrases, the protocols have a wide variety of uses. They can be used for 
routine examinations. They can also be used for a specific problem, such 
as the flu or angina. They can also be used for specific situations where 
a specified set of questions must always be asked or where certain 
information needs to be passed along to the patient. By using the 
protocol, nothing will be forgotten, since all the questions and the 
information are prompted each time the protocol is used. 
The clinical protocols can be stored and used again when the patient 
returns either for entry of new visit information or equally important, as 
a mechanism to review the chart. In the latter use, the patient's chart is 
matched against the protocol. Since all the findings are coded, a 
healthcare professional can quickly see which findings in the chart are 
present that match the medical findings in the protocol. For example, 
after several visits to the healthcare professional for various problems, 
the patient's chart may contain hundreds or thousands of medical findings. 
When the patient returns complaining of a previous problem, the healthcare 
professional can select the matching option so as to compare the findings 
in a protocol for the possible problem with the medical findings in the 
patients chart. 
The creation and use of the protocols will now be described in more detail 
with regard to FIG. 2. First of all, the healthcare professional selects a 
topic or situation for which the healthcare professional wishes to create 
a reusable protocol. The healthcare professional then structures the 
protocol by entering medical findings into the protocol which are 
associated with the topic of the protocol. The healthcare professional can 
also be prompted with lists of associated medical findings by selecting an 
intelligent prompting mechanism. Intelligent prompting is more fully 
disclosed in U.S. patent application Ser. No. 08/609,689 entitled 
"Intelligent Prompting," now pending which is being filed concurrently 
herewith and is expressly incorporated herein by reference. The system 
then prompts the healthcare professional with lists of medical findings 
such as symptoms, other physical history, physical findings, diagnosis, 
tests, and therapy which are listed in the database file 20. The 
healthcare professional simply uses a mouse or other pointing mechanisms 
to select a medical finding to be added to the protocol. 
Once the physical findings have been selected, the healthcare professional 
can select the order in which the medical findings are displayed on the 
display screen 12. Since the medical findings are coded, the selected 
medical findings are automatically placed in the protocol according to how 
the medical findings are originally stored in the database file 20. In 
other words, the system knows which of the selected medical findings are 
symptoms, other history, physical findings, diagnosis, tests, and therapy. 
Thus, the healthcare professional can select the order in which the 
sections can be displayed on the screen. 
Once the protocol has been formed, the healthcare professional can call up 
the desired protocol when needed for a particular patient. During the 
encounter, the healthcare professional can select from the lists of 
medical findings in the protocol those which match or most closely 
resemble the symptoms, history, etc. disclosed by the patient. However, 
before or during the encounter, the healthcare professional may use the 
protocol to review findings from previous encounters related to the 
protocol. The healthcare professional selects the medical findings by 
clicking, pointing, or tapping with a device to enter items on the 
protocol into the patient's chart. Each of these selected medical findings 
may be modified by a list of modifiers such as small, moderate, severe, 
etc. And in addition, the course of the symptoms may also be selected, 
i.e. improving, worsening, etc. In addition, if prescription medicines are 
selected and made part of the protocol, the dosage, the frequency, how the 
medicine is supplied, the amount to dispense, etc. may also be specified 
using prompted lists. In addition, medical findings not illustrated in the 
protocol can be entered into the patient chart using the keyboard 18. 
If the selection of a medical finding is performed on the first few 
characters, for example, 3, of the medical finding, it is entered into the 
patient's chart as a positive statement of the listed finding. Thus, if 
the medical finding is "head trauma" and a pointer points at the first few 
characters of the word "head", the medical finding will be entered into 
the patient's chart as "head trauma". However, if the selection is made to 
the right of the first few characters, the finding is entered into the 
patient's chart as a negative response. For example, if the medical 
finding is "head trauma", and the pointer used to select the medical 
finding points at the word "trauma", the medical finding will be entered 
into the patient's chart as "no head trauma". When the medical findings 
are displayed on the screen, to the left of each medical finding a plus 
sign (+) may be displayed. If the pointer is pointed at the plus sign and 
the physical finding is selected, subsidiary findings giving more detailed 
information about the selected finding are displayed from which the 
healthcare professional may select a more detailed description to be 
entered into the patient chart. For example, the screen may illustrate "+ 
cough". If the healthcare professional clicks on the plus sign, the system 
will display a list of more descriptive information about the cough such 
as "a cough worse in the morning", a "brassy cough", etc. 
FIG. 3 illustrates an example of a protocol created according to one 
embodiment of the present invention. The protocol is for angina and is 
divided into five sections: Symptoms; History; Physical Exam; Diagnoses; 
and Therapy. The protocol first lists a plurality of symptoms which 
usually occur when a person is suffering from angina. As illustrated in 
FIG. 3, the symptoms include among others chest pain occurrence, 
palpitations, difficulty breathing (dyspnea), awaking at night short of 
breath, and dizziness. As noted above, some of the listed symptoms as well 
as other medical findings in the protocol are displayed with a plus sign 
(+) which indicates that more detailed descriptions are available for 
those medical findings. 
The history section lists topics which should be discussed with the patient 
such as a history of smoking cigarettes, medication history, physical 
activity, etc. The physical exam section lists various physical conditions 
to look for during the physical examination of the patient such as 
bradycardia, tachycardia, heart sounds, murmurs, and edema. In addition, a 
protocol for Vital Signs is also referenced which allows the healthcare 
professional to use a protocol within the main protocol. The diagnosis 
section lists history of Diabetes Mellitus and Hypertension where the 
symbol "H" indicates history. Finally, the protocol includes a therapy 
section which lists several medications which can be prescribed to combat 
the problems faced by the patient. 
The principles, preferred embodiments and modes of operation of the present 
invention have been described in the foregoing specification. However, the 
invention which is intended to be protected is not to be construed as 
limited to the particular embodiments disclosed. Further, the embodiments 
described herein are to be regarded as illustrative rather than 
restrictive. Variations and changes may be made by others, and equivalents 
employed, without departing from the spirit of the present invention. 
Accordingly, it is expressly intended that all such variations, changes 
and equivalents which fall within the spirit and scope of the present 
invention as defined in the claims be embraced thereby.