Association of data entries with patient records for a computerized medical record system

Abstract

Apparatus and a method for associating an electronic patient record with the corresponding patient are described. A data processor accesses a patient record not associated with a unique person and compares the patient identification data to corresponding data in a known patient record to identify a set of likely matching patients. An input is provided for selecting a matching patient. Also disclosed is apparatus for providing customized patient discharge instructions relating information in the electronic patient record to patient-specific discharge instructions. A data processor inserts the patient specific instructions into draft instructions, thereby producing patient-specific discharge instructions. An updated version of charting by exception is disclosed, using macros to positively record data on a medical record that is not specifically marked on a template by the attending medical professional. Also described is an apparatus for translating a visual documentation language, communicating specific medical concepts in a highly compact form, to clinically relevant English, enhancing the usability of a pen/digital camera combination for data entry.

1 . Apparatus for associating an unassociated patient record with the corresponding patient, comprising:
 A. a data processor programmed for
 accessing an unassociated patient record not associated with a unique person; 
 identifying at least one of direct and indirect patient identification data stored in said unassociated patient record; 
 accessing a database of at least one known patient record unambiguously associated with a known patient; and 
 comparing said direct or indirect patient identification data from said unassociated patient record to corresponding data in said known patient record to identify a set of one or more known patients that correlate with said direct or indirect patient identification data; 
   B. a display for displaying members of said set of one or more known patients; and   C. a choice input for selecting, from the display of members of said set, a member associated with said unassociated patient record.   
     
     
         2 . The apparatus of  claim 1 , further comprising a digital encoder for capturing said unassociated patient record. 
     
     
         3 . The apparatus of  claim 2 , wherein said digital encoder is a digital camera programmed to capture a series of images from an adjacent position-encoded surface representing the path of movement of said encoder in proximity to the position-encoded surface. 
     
     
         4 . (canceled) 
     
     
         5 . The apparatus of  claim 1 , further comprising a digital encoder for capturing said unassociated patient record, wherein said digital encoder further comprises a position recorder operatively connected to add to said unassociated patient record data indicating where the digital encoder is located while it is being used to record data in the unassociated record. 
     
     
         6 . The apparatus of  claim 1 , further comprising a digital encoder for capturing said unassociated patient record, wherein said digital encoder further comprises a time recorder operatively connected to add to said unassociated patient record time-of-day data indicating when the digital encoder is being used to record data in the unassociated record. 
     
     
         7 . (canceled) 
     
     
         8 . (canceled) 
     
     
         9 . (canceled) 
     
     
         10 . The apparatus of  claim 1 , further comprising programming in said data processor for prioritizing the members of said set of one or more known patients presented by said display according to the calculated probability that each said member of said set should be associated with said unassociated patient record. 
     
     
         11 . The apparatus of  claim 10 , further comprising programming in said data processor for displaying, in connection with at least one member of said set of known patients presented by said display, the calculated probability that the member of said set connected with said probability should be associated with said unassociated patient record. 
     
     
         12 . (canceled) 
     
     
         13 . (canceled) 
     
     
         14 . The apparatus of  claim 1 , wherein said direct patient identification data is selected from a first name, a surname, a middle name, a nickname, a pseudonym, a name suffix, a patient number, a social security number, a photograph, a signature, a fingerprint, body scan data, a cell phone number, patient wristband data, or combinations of these. 
     
     
         15 . The apparatus of  claim 14 , wherein said data processor is programmed for
 identifying at least one item of direct patient identification data and at least one item of indirect patient identification data stored in said unassociated patient record; and   comparing said direct and indirect patient identification data from said unassociated patient record to corresponding data in said known patient record to identify a set of one or more known patients that correlate with said direct or indirect patient identification data.   
     
     
         16 . The apparatus of  claim 15 , wherein said indirect patient identification data is selected from one or more items of medical complaint data, one or more items of symptom data, one or more items of diagnosis data, or combinations of these. 
     
     
         17 . (canceled) 
     
     
         18 . The apparatus of  claim 1 , wherein said indirect patient identification data is selected from medical complaint data, medical history data, age data, gender data, diagnosis data, symptom data, patient physical description data, patient location data, time of treatment data, direct or indirect identification data for a person accompanying the patient, attending medical personnel data, patient address data, patient telephone number data, patient e-mail address data, patient insurance data, patient clothing data, patient skin marking data, data identifying a person accompanying the patient, or any combination of these. 
     
     
         19 . The apparatus of  claim 1 , further comprising a transmitter for presenting said display to a location separated from said data processor. 
     
     
         20 . The apparatus of  claim 1 , further comprising a transmitter for presenting the selection made at said choice input to a location remote from said choice input. 
     
     
         21 . (canceled) 
     
     
         22 . (canceled) 
     
     
         23 . The apparatus of  claim 1 , wherein said data processor is programmed to present on said display, in association with data identifying the patient, items of said patient identification data relied on to determine the identity of the patient. 
     
     
         24 . (canceled) 
     
     
         25 . (canceled) 
     
     
         26 . (canceled) 
     
     
         27 . (canceled) 
     
     
         28 . (canceled) 
     
     
         29 . The apparatus of  claim 1 , further comprising programming in said data processor to merge said unassociated patient record with the record of the same patient in said database after the unassociated patient record has been associated with said patient. 
     
     
         30 . (canceled) 
     
     
         31 . (canceled) 
     
     
         32 . A method for associating an unassociated patient record with the corresponding patient, comprising:
 A. accessing an unassociated patient record not associated with a unique person;   B. identifying at least one of direct and indirect patient identification data stored in said unassociated patient record;   C. accessing a database of at least one known patient record unambiguously associated with at least one known patient;   D. comparing said direct or indirect patient identification data from said unassociated patient record to corresponding data in said known patient record to identify a set of one or more known patients that correlate with said direct or indirect patient identification data;   E. displaying members of said set of one or more known patients; and   F. receiving user input selecting, from the display of members of said set, a member corresponding to said unassociated patient record.   
     
     
         33 . (canceled) 
     
     
         34 . The method of  claim 32 , wherein said capturing step is carried out by capturing a series of images from an adjacent position-encoded surface representing the path of movement of a digital encoder in proximity to the position-encoded surface. 
     
     
         35 . The method of  claim 34 , further comprising marking the position-surface. 
     
     
         36 . The method of  claim 34 , further comprising associating with said unassociated patient record the location where a patient data input was used to input at least a portion of said unassociated patient record. 
     
     
         37 . The method of  claim 34 , further comprising associating with said unassociated patient record the time when a patient data input was used to input at least a portion of said unassociated patient record. 
     
     
         38 . The method of  claim 32 , further comprising prioritizing the members of said set of one or more known patients presented by said display according to the calculated probability that each said member of said set should be associated with said unassociated patient 
     
     
         39 . The method of  claim 38 , further comprising displaying, in connection with at least one member of said set of known patients presented by said display, the calculated probability that the connected member of said set should be associated with said unassociated patient record. 
     
     
         40 . (canceled) 
     
     
         41 . (canceled) 
     
     
         42 . (canceled) 
     
     
         43 . (canceled) 
     
     
         44 . The method of  claim 32 , wherein said indirect patient identification data is selected from medical complaint data, medical history data, age data, gender data, identifying personal characteristic data, diagnosis data, symptom data, patient physical description data, patient location data, time of treatment data, direct or indirect identification data for a person accompanying the patient, attending medical personnel data, patient address data, patient telephone number data, patient e-mail address data, patient insurance data, patient clothing data, patient skin marking data, data identifying a person accompanying the patient, or combinations of these. 
     
     
         45 . (canceled) 
     
     
         46 . (canceled) 
     
     
         47 . (canceled) 
     
     
         48 . The method of  claim 32 , further comprising presenting on said display, in connection with data identifying the patient, items of said patient identification data relied on to associate the patient with the unassociated patient record. 
     
     
         49 . (canceled) 
     
     
         50 . (canceled) 
     
     
         51 . (canceled) 
     
     
         52 . (canceled) 
     
     
         53 . The method of  claim 32 , further comprising merging said unassociated patient record with the record of the same patient in said database after the unassociated patient record has been associated with said patient. 
     
     
         54 . - 70 . (canceled)