Patent Application
20150227501
This invention relates generally to operative notes and, more particularly to an improved system and method for generating operative notes.
An operative note is a written record regarding a surgical procedure, such as an operation to repair a joint. Operative notes are important for documentation of the surgical procedure performed, later consultation with patients, other medical professionals and third parties, such as insurance providers. Appropriate documentation of surgical procedures is often a time consuming task. Moreover, timely documentation can be difficult to prepare in an efficient manner. Typically, hospitals invest in dictation systems in efforts to decrease time spent in preparing operative notes and increase efficiency. However, dictation systems are often very costly and suffer from errors in transcription. Also, surgeon compliance with timely dictation is often inadequate.
Therefore, there is a need for an improved method for generating operative notes.
Accordingly, the present invention is directed to a system and method for preparing operative notes that remedies the shortcomings of the prior art.
The present invention, according to an embodiment, is directed to a system for graphically generating operative notes, the system comprising: a processor; an input device coupled to the processor; a display device coupled to the processor; and a memory system coupled to the processor. The memory system has graphical representations of anatomical structures, diagnoses and medical procedures. The memory system also has text descriptions corresponding to the graphical representations. The memory system also contains instructions executable on the processor for: displaying the graphical representations on the display device for a user to select; receiving selected graphical representations from the user; using text corresponding to the selected graphical representations to generate text for operative notes; and allowing the user to edit the generated text using the input device.
The memory system may also have data regarding at least one of a patient, a medical facility and medical personnel; and the instructions executable on the processor may include instructions for using the data regarding at least one of a patient, a medical facility and medical personnel to generate text for operative notes. The memory system may also have text descriptions for pre-operative diagnoses, procedures, anesthesia, indications or post-operative diagnoses; and the instructions executable on the processor may include instructions for selecting from the text descriptions based on the selected graphical representations and the data regarding at least one of a patient, a medical facility, a medical procedure and medical personnel to generate text for operative notes.
The instructions executable on the processor may provide graphical representations based on the user of the system and based on a medical procedure. The system may reside on a mobile computing device. The display device may be a display screen of the mobile computing device and the input device may be a touch screen of the mobile computing device. The memory system may have operative photographs of a patient. The instructions executable on the processor may prompt the user to select operative photographs for inclusion in operative notes and for including selected operative photographs in the operative notes.
In an additional embodiment, the present invention is directed to a method for generating operative notes, the method having the steps of: providing a user with graphic representations of anatomical structures, diagnoses and medical procedures; prompting the user to graphically indicate at least one diagnosis using the graphic representations; receiving a graphic indication of at least one diagnosis from the user; generating operative note text from the received graphic indication of at least one diagnosis; prompting the user to graphically indicate at least one medical procedure using the graphic representations; receiving a graphic indication of at least one medical procedure from the user; and generating operative note text from the received graphic indication of at least one medical procedure.
The method may also have the steps of: prompting the user to login to the system using a password; receiving the password from a user; authenticating the password received from the user; prompting the user to select from a plurality of different cases; receiving a case selection from the user; retrieving data corresponding to the selected case from a memory; and populating a portion of an operative note with the retrieved data. The retrieved data may contain a patient name, a patient sex, a patient date of birth, and a patient medical record number.
The method may also have the steps of: storing information about at least one of a medical facility and medical personnel in a storage device; retrieving the information about at least one of a medical facility and medical personnel from the storage device; and populating a portion of an operative note based on the retrieved information about at least one of a medical facility and medical personnel from the storage device.
The method may also have the steps of: storing text descriptions for diagnoses, medical procedures, anesthesia, indications and post-operative diagnoses in a storage device; and selecting text from the text descriptions based on the received graphic indication of at least one diagnosis, the received graphic indication of at least one medical procedure, the retrieved data corresponding to the selected case and the retrieved information about at least one of a medical facility and medical personnel.
The method also has the steps of prompting the user to review a draft operative note; receiving edits from the user; and generating a final operative note. The method also has the steps of: prompting the user to select from a plurality of destinations for the final operative note; receiving at least one destination selection from the user; and sending the final operative note the to the at least one selected destination.
The step of providing the user with portions of an operative note containing graphic representations may include selecting graphic representations based on the user. The steps of generating operative note text from the received graphic indication of at least one diagnosis and generating operative note text from the received graphic indication of at least one medical procedure may further include selecting text based on the user.
The present invention, according to additional embodiment, is directed to a system for graphically generating operative notes, the system comprising: an operative note generating module further comprising; a processor; a first memory system coupled to the processor, the memory system comprising graphical representations of anatomical structures, diagnoses, and medical procedures; an input device coupled to the processor; and a display device coupled to the processor; a data storage system coupled to the operative note generating module, the data storage system further comprising data regarding a patient, a medical facility and medical personnel. The operative note generating module processor is configured to: provide the graphical representations to a user for selection; receive selected graphical representations from a user; use the selected graphical representations to generate text for operative notes; and use the data regarding at least one of a medical facility and medical personnel to generate text for operative notes.
The first memory system may also have text descriptions for at least one of pre-operative diagnoses, procedures, anesthesia, indications and post-operative diagnoses. The processor may be further configured to select from the text descriptions based on the selected graphical representations and the data regarding a patient, a medical facility, a medical procedure and medical personnel to generate an operative note.
The system may reside on a mobile computing device where the display device is a display screen of the mobile computing device and the input device is a touch screen of the mobile computer device.
The features, aspects and advantages of the present invention will become better understood with regard to the following description, appended claims and accompanying figures wherein:
In the following description of the preferred embodiments, reference is made to the accompanying drawings which show by way of illustration specific embodiments in which the invention may be practiced. Wherever possible, the same reference numbers will be used throughout the drawings to refer to the same or like parts. It is to be understood that other embodiments may be utilized and structural and functional changes may be made without departing from the scope of the present invention.
An operative note typically contains information about the hospital or surgery center at which the operation is performed and the date and time of the operation. Additionally, the operative note typically contains patient information, such as patient name, medical record number and date of birth. Additionally, the operative note contains staff information, such as the names of the surgeon and any assisting physicians or staff. Additionally, the operative note typically contains preoperative diagnoses, indications and postoperative diagnoses. Additionally, the operative note typically contains operation information, such as the objectives of the operation and a description of the procedure performed, including anesthesia administered.
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The system 10 has a processor 12 operatively coupled to a memory system 14. The memory system 14 may include one or more memory devices (RAM, ROM, disk, or other storage format). The system 10 has a computer program executing on the processor for generating operative notes. The processor 12 is operatively coupled to at least one display device 15. The processor is operatively coupled to at least one input device 16, such as a keyboard, mouse, touchscreen or touchpad. The note generator may also be operatively coupled to a computer 18, such as a tablet computer for receiving input as will be further explained below. The system 10 may be coupled to additional systems 20, such as medical record storage systems, or systems for storing other information. The system 10 may be coupled to the computer 18 and the additional systems 20 via a local area network or over a wide area network such as the Internet.
In an embodiment, the system 10 is located on a server remotely accessible by the computer 18. For example, the computer 18 may be a tablet computer, such as an Apple Computer® Ipad®, that accesses the system server via a wireless network. The system server may be accessible via a local area network. Additionally, the system server may be a cloud computer accessible over the Internet.
Data is loaded in the memory system 14 so that the program may use the data for generating a draft operative note. The data may be loaded in a particular format (e.g., a common spreadsheet format, comma delimited text, or other format). The data may be stored in several different databases in the memory system, with each database being designed to hold data relevant to a different part of an operative note.
In an embodiment, the data saved in the data system 14 includes information likely to recur in various reports at a given surgery center or hospital for given surgeons and staff. For example, information about the name and address of the hospital or surgery center is saved in a database in the memory system 14. Information about doctors, surgeons and staff is saved in a database in the memory system 14.
Information about patients is saved in a database in the memory system 14 or in an additional system 20 accessible by the processor 12. Patient information may include, for example, patient name, sex, date of birth, medical identification number as well as diagnosis information.
Language for typical pre-operative diagnoses, procedures, anesthesia, indications and post-operative diagnoses is saved in a database in the memory system 14. To ease population of the database, language from previously generated operative notes may be copied and saved. The language is highly customizable and may be saved for each surgeon. Moreover, the language is intended to be language universal in that when specific pre-operative diagnoses, procedures, anesthesia, indications and post-operative diagnoses are selected those items may be translated into multiple different languages.
Sample indication text may be stored in the memory system 14 for different symptoms. For example, “The patient is a {xx} year old { sex} who presents with a chief complaint of { side} {extremity} pain and has failed a conservative treatment program. {He/She} has been informed of the indications, risks, benefits, and alternatives to this surgery and does wish to proceed. {He/She} understands that the risks include infection, stiffness, nerve or vascular injury, failure to improve, need for reoperation, and anesthetic complication.” The bracketed portions may be variables that are populated by the program based upon stored patient information, such as the sex and age of the patient and based upon stored medical procedure information. Some indications may be procedure specific and some indications may be generic for all procedures.
Sample procedure text may be stored in memory system 14 describing patient set-up for different procedures (such as knee arthroscopy and shoulder arthroscopy). For example, “The patient was placed on the operating room table. All extremities were carefully padded. A tourniquet was applied on the operative leg. The lower extremity was prepped and draped in a sterile fashion. After administration of IV antibiotics, the lower extremity was exsanguinated and the tourniquet was inflated. An inferolateral portal was established with a #11 blade. The inferomedial portal was established under direct arthroscopic visualization.”
Language saved for typical pre-operative diagnoses, procedures, anesthesia, indications and post-operative diagnoses is highly customizable. Preferably, language is held in variables with standard text that can be modified by the end user. For example, the term “menisectomy” may be translated as “a partial [medial/lateral] menisectomy was performed using a combination of shave and basket punches to trim the meniscus to a stable surface” or “a [medial/lateral] meniscoplasty was achieved by carefully smoothing the torn edges of the meniscus using a shave and electrothermal device” or customized to whatever the surgeon/doctor prefers. Surgeon preferences, including typical language, may be saved to a cloud storage system accessible over the Internet. The text generator can be programmed to perform translations for different languages, such as English, German and Japanese.
Different anatomical images and/or diagrams are stored in the memory system 14 for use by the program in generating a draft operative note. The images and/or diagrams represent different anatomical structures related to the procedure performed. The images and associated workflow may be customized by surgeon and procedure type. The images and/or diagrams may be coded with image maps so that when a portion of an image is selected by a user, such as using the input device 16 or the input computer 18, the program may use the selection to further generate text for the draft operative note. In an embodiment, the program has an overlay such that markings, such as loops or lines made over the images and/or diagrams can be used to generate text for the draft operative note.
Preoperative and operative images may be stored in the memory system 14 for use by the program in generating a draft operative note. The images and associated workflow may be customized by surgeon and procedure type.
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The user is prompted to provide entries to those sections that could not be automatically populated. The user may be presented with a finite number of options from which to select based on already known information, such as in drop down menus or via radio button selections. For example, the user may be prompted to select an assistant surgeon from a pull-down menu of assistant surgeons at the facility. For example, the user may be prompted to select an anesthesia type from a list of different anesthesia types associated with a given surgical procedure. Certain default selections may be preselected by the system, such as those options most frequently selected by the user (or all users) in the past.
Additionally, a user may have the option to select a free form field (labeled such as “other”) and type language into the form. The user may also enter language into the operative note using voice to text insertion. A user may not be allowed to navigate away from a given screen until the user has entered and confirmed certain information on a given screen.
A user may be presented with multiple screens for sections of the operative note. Some screens may prompt a user to graphically enter information. As shown in
The system presents a user with screens for editing the diagnosis and procedures. As shown in
In an additional embodiment, the location, shape and orientation of user notations are used to select and customize text. For example, if a user draws a line across approximately three quarters of a knee cartilage, the system detects that the user is drawing a 75% tear of the cartilage at a very specific location of the cartilage. The system then translates this concept into meaningful text. Alternatively, a user may select an area of the image (such as by tapping a touchscreen or clicking a mouse) and be prompted to select from various problems associated with the structure in the portion of the image selected by the user.
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In an embodiment, the user is prompted to add operative photographs of the patient showing the performed procedure and the results of the procedure for inclusion in the report. The procedure for adding operative photographs may be the same as described above with reference to
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Many elements of the draft operative report in
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Information from the operative report may be used to create patient reports or other reports. Additionally, information from patient reports or other reports prepared by the surgeon for a given patient and procedure may be imported into the draft operative note to streamline preparation of the operative note.
According to an embodiment, the present invention allows for graphic indication of diagnoses and procedures; further refinement of the diagnoses and procedures using menus specific to the indicated diagnoses and procedures; and generation of a detailed textual operative note that does not sound like canned or machine generated text. This process is aided by customizing the diagnoses and procedures using preferences of, for example, a user, a hospital and a patient. The present invention, according to an embodiment allows for users, such as surgeons, to store diagnoses and procedure preference information as well as descriptive text in one of the additional systems 20 accessible by the system 10. In an embodiment, the other system 20 where the user's preferences are stored is a cloud based memory device.
Advantages for the doctor or surgeon include, quick and easy generation of post-operative notes. No dictation is necessary. Operative notes are immediately accessible for use in the doctor or surgeon's EMR. Moreover, the present invention allows for graphical representation of surgical procedures, to augment or replace text, to aid a reader in more quickly and easily comprehending the pathology and surgical procedures performed.
Advantages for a hospital or surgery center include: substantially decreased transcription costs, immediate, timely operative note integration into a patient's chart, and improved surgeon compliance. The present invention allows for improved compliance with government meaningful use mandates.
There is disclosed in the above description and the drawings, a system and method for creating operative notes which fully and effectively overcomes the disadvantages associated with the prior art. However, it will be apparent that variations and modifications of the disclosed embodiments may be made without departing from the principles of the invention. The presentation of the preferred embodiments herein is offered by way of example only and not limitation, with a true scope and spirit of the invention being indicated by the following claims.
Any element in a claim that does not explicitly state “means” for performing a specified function or “step” for performing a specified function, should not be interpreted as a “means” or “step” clause as specified in 35 U.S.C. §112.
This application claims priority of U.S. Provisional Patent Application No. 61/937,171, filed on Feb. 7, 2014, entitled GRAPHIC OPERATIVE NOTES, the entire contents of which are hereby incorporated herein by reference.
| Number | Date | Country | |
|---|---|---|---|
| 61937171 | Feb 2014 | US |
