US 8,712,791 B2 · Systems and methods for documenting medical findings of a physical examination

Abstract

An electronic system and a method for efficiently documenting medical findings that consist of both a problem and a location on or in the body. This invention further provides a method for documenting multiple problems in related body locations. This invention further provides a method for efficiently issuing orders associated with medical findings that consist of both a problem and a location on or in the body. The invention is able to enhance efficiency during the Physical exam making the invention an essential component of the physician's practice workflow. This, in turn, will enable the invention to serve as a single point of integration for a vast array of useful electronic tools and information. For example, in a computer-implemented system and method for documenting one or more medical findings having a body location and a type of medical finding, the method includes the steps of: displaying a body location selection view for a user, the user selecting a body location, the system then displaying a means of selecting possible types of medical findings, the system also then displaying a means of selecting to display a more detailed body location selection view, wherein the user selecting a type of medical finding causes the system to store a finding comprising the user-selected location and problem, and wherein the user selecting to display a more detailed body location selection view causes the system to display a more detailed body location selection view. The method may further include the finding types that may be selected are of a group of finding types and further comprising a means for selecting a different group of finding types to be displayed. Moreover, the groups of finding types each may correspond to a set of finding types related to one system of the body. The system may include a means for selecting one or more appropriate procedures that may be performed at the selected body location and a means for recording an annotation regarding the selected location of the body. The means for recording an annotation may be selected from a group including selecting a pre-generated annotation, recording a text annotation, recording a graphical annotation, recording a sound annotation, and recording a photographic annotation.

Claims23

Dependent claims

A method for documenting medical findings of a physical examination, the method comprising:

displaying on an interface device a first interface including a first graphical representation of anatomical features;
accepting from a user via the interface device a first selection of an anatomical feature by clicking on a specific part of the anatomical feature on the first graphical representation of anatomical features;
displaying on the interface device a second interface including a second graphical representation of anatomical features and a first set of controls relating to a first plurality of medical conditions in response to accepting the first selection, the second graphical representation of anatomical features and the first set of controls displayed simultaneously without at least partially obstructing each other;
accepting from the user via the interface device a second selection from the second graphical representation of anatomical features;
and
displaying on the interface device a third interface including a second set of controls relating to a second plurality of medical conditions;
wherein the first set of controls includes a tri-state control comprising one graphical icon configured to indicate one of three states including present, not present, or not entered,
the method further comprising:
accepting from the user via the interface device an indication of a state of not present, the indication resulting from the user selecting the graphical icon twice and wherein the graphical icon displays a state of not entered for an empty box, a state of present for a checkmark, and a state of not present for a slash mark;
and
storing data associating the state accepted from the user with the first selection and displaying the state accepted from the user in a list of findings.

8 more elements

A device for documenting medical findings of a physical examination, the device comprising:

an electronically readable media for storing instructions;
a processor, associated with the electronically readable media, that executes the instructions;
and
the instructions comprising:
instructions for displaying a first interface including a first graphical representation of anatomical features;
instructions for accepting from a user a first selection of an anatomical feature by clicking on a specific part of the anatomical feature on the first graphical representation of anatomical features;
instructions for displaying a second interface including a second graphical representation of anatomical features and a first set of controls relating to a first plurality of medical conditions in response to accepting the first selection, the second graphical representation of anatomical features and the first set of controls displayed simultaneously without at least partially obstructing each other, wherein the first set of controls includes a tri-state control comprising one graphical icon configured to indicate one of three states including present, not present, or not entered;
instructions for accepting from the user an indication of the state of not present, the indication resulting from the user selecting the graphical icon twice and wherein the graphical icon displays a state of not entered for an empty box, a state of present for a checkmark, and a state of not present for a slash mark;
instructions for storing data associating the state accepted from the user with the first selection;
instructions for displaying the state accepted from the user in a list of findings;
instructions for accepting from the user a second selection from the second graphical representation of anatomical features;
and
instructions for displaying a third interface including a second set of controls relating to a second plurality of medical conditions.

10 more elements

Dependencies are inferred from the claim text.

Systems and methods for documenting medical findings of a physical examination

Life of this patent

Systems and methods for documenting medical findings of a physical examination

Life of this patent

Abstract

Claims23