U.S. patent application number 11/753742 was filed with the patent office on 2007-10-04 for clinical documentation system for use by multiple caregivers.
Invention is credited to Christopher Alban, Khiang Seow.
Application Number | 20070233524 11/753742 |
Document ID | / |
Family ID | 25490037 |
Filed Date | 2007-10-04 |
United States Patent
Application |
20070233524 |
Kind Code |
A1 |
Alban; Christopher ; et
al. |
October 4, 2007 |
CLINICAL DOCUMENTATION SYSTEM FOR USE BY MULTIPLE CAREGIVERS
Abstract
A computer-based system for recording, storing, and accessing
clinical documentation in an acute care setting is provided. In an
embodiment of the invention, a single electronic database or
repository for storing clinical patient notes, provides multiple
points of read/write access via a user interface operating on one
or more client computers that are in real-time communication with
the repository.
Inventors: |
Alban; Christopher;
(Madison, WI) ; Seow; Khiang; (Madison,
WI) |
Correspondence
Address: |
BOYLE FREDRICKSON S.C.
840 North Plankinton Avenue
MILWAUKEE
WI
53203
US
|
Family ID: |
25490037 |
Appl. No.: |
11/753742 |
Filed: |
May 25, 2007 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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09950158 |
Sep 10, 2001 |
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11753742 |
May 25, 2007 |
|
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60233950 |
Sep 20, 2000 |
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Current U.S.
Class: |
705/3 |
Current CPC
Class: |
A61F 2/95 20130101; A61F
2002/9511 20130101; G06Q 10/00 20130101 |
Class at
Publication: |
705/003 |
International
Class: |
G06Q 50/00 20060101
G06Q050/00 |
Claims
1. A system for documenting patient information from multiple
caregivers comprising: a database for storing free-text patient
notes as records linked to a patient, different types of
caregivers, and timestamps; and a user interface operating in a
first mode to display a longitudinal view of the records for a
given patient according to timestamp order for all caregivers, and
in a second mode to display a longitudinal view of the records for
a given patient according to timestamp order for a single
caregiver.
2. A system for documenting patient information from multiple
caregivers comprising: a database for storing free text patient
notes as records linked to a patient and to a first timestamp
indicating a date of writing of the patient record by a given
caregiver; and a user interface operating to select for viewing by
the given caregiver patient notes from multiple caregivers having a
first timestamp after a latest timestamp of a patient record
written by the given caregiver.
Description
[0001] This application is a continuation of U.S. application Ser.
No. 09/950,158 filed Sep. 10, 2001, which application claims
priority to U.S. Provisional Application Ser. No. 60/233,950, filed
Sep. 20, 2000, the disclosure of which is hereby expressly
incorporated herein by reference.
FIELD OF THE INVENTION
[0002] The invention relates generally to information management
systems for use within the healthcare enterprise, and more
particularly, to a system for documenting clinical patient
information generated by multiple caregivers.
BACKGROUND OF THE INVENTION
[0003] During the course of a patient's stay in an inpatient or
acute care facility, the patient will be seen by a variety of
health care providers as they review the patient's status,
recommend treatments and protocols, provide care, order tests, etc.
Providers must record all of their activities and decisions for the
patient, and efficient communication of this information between
all of a patient's caregivers is key to the problem of providing a
patient with the best possible care.
[0004] Existing approaches to this problem typically center on some
kind of shared patient record. A shared paper chart kept in or near
the patient's room represents perhaps the most common but also the
least effective approach. A shared paper chart offers very limited
security and virtually no simultaneous access for either viewing or
editing the patient's hospital record. What's more, as information
is eventually added to the patient's record from a large number of
caregivers, it becomes increasingly difficult and time consuming to
identify and review appropriate information for a particular
situation.
[0005] A computer-based approach can solve some of these problems
by providing a central repository for storing and accessing
clinical documentation for a patient, and in recent years many
computer-based clinical documentation systems have been conceived
and implemented for both ambulatory and acute care settings.
However, these systems typically demonstrate weaknesses and
problems that result in a failure to ensure efficient communication
between a patient's acute caregivers. Problems with these systems
include a failure to address one or more of the following
needs:
[0006] providing a single point of access to the information
recorded by all of the patient's caregivers during an acute care
episode;
[0007] providing simultaneous access to a patient's chart for both
viewing and editing from different locations while maintaining data
integrity;
[0008] providing role-based security to limit each caregiver's
viewing and editing access to a patient's chart;
[0009] providing user-linked time-stamps for both data entry and
review that a) make it easy to present a longitudinal view of the
patient record, b) provide a means for a user to quickly see
information that's been added to the patient's record since the
user's last review, and c) providing for note cosign by one or more
caregivers;
[0010] providing for storing and sorting patient notes according to
caregiver's roles, service areas and etc.;
[0011] providing easy to use filter and search tools that allow a
caregiver to quickly identify and review clinically appropriate
information for a given situation;
[0012] providing for entering data other than entirely manual
keyboard entry, for example automated text-entry options,
dictation, voice recognition, etc.;
[0013] providing for incorporating available information relevant
to a patient's acute care episode, for example emergency room (ER)
notes, hospital discharge summaries etc.
[0014] Thus, there is a need for a clinical documentation system
that addresses these needs within the healthcare enterprise.
BRIEF DESCRIPTION OF THE DRAWINGS
[0015] FIG. 1 is a block diagram illustrating a patient health
record system in accordance with an embodiment of the
invention.
[0016] FIG. 2 is a block diagram illustrating a graphic user
interface of the patient health record system illustrated in FIG.
1.
[0017] FIG. 3 is a graphic representation of the graphic user
interface illustrated in FIG. 2.
[0018] FIG. 4 is a graphic representation of a new/edit window
function in accordance with an embodiment of the invention.
[0019] FIG. 5 is a graphic representation of a cosign function in
accordance with an embodiment of the invention.
[0020] FIG. 6 is a graphic representation of a filter function in
accordance with a preferred embodiment of the invention.
[0021] FIG. 7 is a flowchart representing the general workflow
associated with a system in accordance with an embodiment of the
invention.
[0022] FIG. 8 is a flowchart representing a workflow for adding,
editing or deleting a patient note in accordance with an embodiment
of the invention.
[0023] FIG. 9 is a flowchart representing a workflow for addending
a patient note in accordance with an embodiment of the
invention.
[0024] FIG. 10 is a flowchart representing a workflow for filtering
patient notes in accordance with an embodiment of the
invention.
[0025] FIG. 11 is a flowchart representing a workflow for
retrieving and displaying a last entered patient note in accordance
with an embodiment of the invention.
[0026] FIG. 12 is a flowchart representing a workflow for searching
patient notes in accordance with an embodiment of the
invention.
[0027] FIG. 13 is a flowchart representing a workflow for
annotating a patient note in accordance with an embodiment of the
invention.
[0028] FIG. 14 is a flowchart representing a workflow for sorting
patient notes in accordance with an embodiment of the
invention.
[0029] FIG. 15 is a flowchart representing a workflow for cosigning
a patient note in accordance with an embodiment of the
invention.
[0030] FIG. 16 is a flowchart representing a workflow for printing
and/or copying a patient note in accordance with an embodiment of
the invention.
DETAILED DESCRIPTION OF THE INVENTION
[0031] A computer-based system for recording, storing, and
accessing clinical documentation in an acute care setting is
provided. In an embodiment of the invention, a single electronic
database or repository for storing clinical patient notes is
accessed via a plurality of client workstations coupled, e.g.,
networked, to the single electronic database providing multiple
points of read/write access via a user interface operating on one
or more client computers that are in real-time communication with
the repository.
[0032] The system may provide for storing and sorting patient notes
according to caregiver's roles, service areas, etc., and may
include a data access scheme that provides simultaneous view access
to a patient's chart for both viewing and editing, and which
automatically locks an individual note from write access when it is
being edited by someone else. In addition, an embodiment of the
invention may include a role-based user-security scheme that can be
configured to limit each caregiver's viewing and editing access to
a patient's chart to only appropriate types of information. An
embodiment of the invention may also include a user-linked
time-stamping mechanism for both data review and entry and a
corresponding user interface that a) presents a longitudinal view
of the patient record and b) permits a user to easily filter for
information that's been added to the patient's record since the
user's last review. Longitudinal view refers to an ability to
display and view notes from a patient's previous contacts over time
providing essentially a holistic view of the patient's contact
history.
[0033] An additional embodiment of the invention may provide for
importing (either manually or automatically) available information
relevant to a patient's acute care episode from external sources
where necessary, for example ER notes, hospital discharge
summaries, etc., and for viewing, filtering, and searching this
information along with the other patient notes. Still further, an
embodiment of the invention may provide for importing, storing and
viewing graphic and other multi-media information and linking it to
the appropriate entries in a patient's acute care record.
[0034] A system according to the embodiments of the invention may
include a user interface coupled to the enterprise health record
system to provide single point of access for information recorded
by all of a patient's caregivers during an acute care episode. The
user interface may include pre-defined role-based filters and/or an
easy to use custom filter and search options that allow a caregiver
to quickly identify and review clinically appropriate information
for a given situation. The user interface allows caregivers to
choose between a number of data entry options, including manual
keyboard entry, automated text-entry, dictation, voice recognition,
etc. The user interface may also allow caregivers to file a note
(to store it on the server) and mark it either as complete or
pending, and may further allow a caregiver to edit a note while
also reviewing other information in the patient's acute care
record. In accordance with the embodiments of the invention, the
user interface makes it easy for users to take appropriate follow
up actions for specific entries in a patient's acute care record,
for example, for a supervising physician to review, document, and
cosign an entry made by a resident.
[0035] Referring to FIG. 1, an enterprise patient health record
system 10 includes a number of data elements 12 for supporting the
information needs of the healthcare enterprise. As shown in FIG. 1,
the system 10 includes a patient ID element 14, a patient encounter
element 16, a clinical notes element 18, a user security element 20
and a providers element 22. These elements, for example, provide to
the system 10 respective data services. For example, the patient ID
14 includes a data structure for organizing and storing patient
identification information and may incorporate processing and
communication capability to allow the element to interface with the
other elements of system 10 for receiving, organizing and storing
patient information and for retrieving and delivering patient
information. Of course the processing and communication capability
may be centralized within the system 10, in which case the
respective element would include just the appropriate data
structure for organizing and retaining data. The system 10 drives a
graphic user interface (GUI) 24 shown in FIG. 2. The GUI 24 may be
supported on any number of client workstations coupled, e.g.,
networked, to the system 10. As such, a user may log into the
system 10 at any of the workstations from virtually any location,
including remotely from the healthcare facility via a private
network or a public network, e.g., the Internet.
[0036] The GUI 24 may have a web browser or other suitable
appearance, and includes an activity header 26, an activity toolbar
28, a notes toolbar 30, a notes listing window 32 and a notes
viewing window 34. The activity header 26 may provide current
patient information, such as patient name, sex, age, insurance and
other patient demographic information. The activity toolbar 28
contains point-and-click activity selections, which allow the user
to activate various activities within the system 10, including the
patient's notes activity.
[0037] Referring generally to FIG. 3, the notes listing window 32
provides the user with a listing of all or selectively filtered
notes for the current patient. Selecting a note from the listing
window 32 causes the note to be displayed in the notes viewing
window 34. Notes within the listing window 32 may be color coded
and/or may include a graphic representation, e.g., an icon, to
depict the author, author type, medical service, etc., associated
with the note. The author, author type, medical service, note time
and date, etc., may be depicted with the body of the note in the
viewing window 34. Additionally, scrolling may be provided to
facilitate viewing of the notes within the viewing window 34.
[0038] With more particular reference to FIG. 3, the notes listing
window 32 may include a plurality of note tabs 36 indicating
various categories of notes. The user may click on one of the tabs
to display a list of notes for that category. Only the notes
written by authors that match a current filter criteria, described
more fully below, are displayed. The notes listing window also
includes an author symbol column 38. Within the author symbol
column 38, a graphic representation, i.e., an icon or symbol, may
be displayed indicating the author type. The notes listing window
also includes an author segment 40 to display the name of the
provider who wrote the note, the service segment 42 to display the
name of the medical service to which that user belongs and an
author type segment 44 indicating the role of the provider writing
the note. The specific authors types listed may be configured by a
system administrator and/or by the user. A cosign segment 46
displays the word "required" for notes requiring a cosign. When a
cosign is required, a cosign button (not depicted) appears adjacent
the note in the listing window 32. The cosign button opens a cosign
window (FIG. 5) to allow the cosigning user(s) to enter the
required cosign(s). A filed segment 48 displays the date and time
the note was accepted., and a category segment 50 indicates the
category of the note when all notes are being displayed. In
addition, a copy button 54 appears adjacent each note in the
viewing window 34. The copy button 54 causes a copy of the text of
the note to be copied to a clipboard, e.g., the Windows clipboard,
allowing the text to be pasted into a new note and/or into a
different application.
[0039] Within the notes toolbar 30 there are a number of buttons 52
corresponding to functions related to the patient's notes activity
allowing the user to select a particular function using a
point-and-click or similar action. New note and edit note functions
each opens a new/edit note window 56 shown in FIG. 4 and allows the
user to enter the new note or edit the pending note. The edit notes
function may only be used with the user's own notes, and the user
is not permitted to edit another user's notes. Moreover, once a
note is accepted, it generally may not be edited or deleted. The
window 56 includes a number of fields including a cosign required
box 58, which allows the user to indicate whether a cosign for the
note will be required. A note type selection 60 is provided to
allow the user to enter the category of the note, such as: progress
notes, consult notes, procedures, History and Physical notes,
Discharge summaries and Emergency Department notes.
[0040] Another note type that may be provided is referred to as a
"tagged" note. A tagged note may generally be any note type
supported by the system 10, but the tagged note includes tag data.
The tag data sub-classifies or sub-types the note. One feature of
the tag data is that it allows the notes to be efficiently
segregated and collected for report generation. For example,
certain notes may relate only to casual or general comments that
would not ordinarily by reported. These notes might be tagged
"casual comments." Other notes may relate to the patient's
treatment plan that would be reported. These notes might be tagged
"treatment plan." A filter search by author would retrieve both the
casual comments and the treatment plan notes, while a search by
author and the "treatment plan" tag would provide only those notes
by that author that are also tagged "treatment plan."
[0041] The user enters the note text in a note text box 62. Note
text may be entered using many common wordprocessing functions
including typing, copying, cutting and pasting, by using drafting
assist tools, such as the SmartSet documentation tool available
from Epic Systems Corporation of Madison, Wis., or by dictation,
which may include voice recognition. The user selects the entry
method using the appropriate one of the buttons 59. Using dictation
alone causes the note to be recorded for later transcription to
text, while using dictation in conjunction with voice recognition
may provide an instantaneous text transcription. A note editing
toolbar 64 provides text editing and formatting functions to assist
the user in entering the note text.
[0042] When a cosign is required, the cosigning user opens a cosign
note window 66 shown in FIG. 5 using the cosign button 52 (FIG. 3).
The type of cosign required is specified by cosign data specified
for the note by the author. The required cosign may specify a
single caregiver, for example, the author's attending physician.
Alternatively, the required cosign may specify cosigns from
multiple caregivers from one or more medical services. The cosign
window 66 allows the cosigning user(s) to indicate that the user's
note has been reviewed and approved by the cosigner. The user's
note is displayed in a note text window 68, and the cosigning
user(s) enters their approval/disapproval and any appropriate
comments in a cosign text box 70. Once the cosigning user(s)
accepts the cosign note, the original note and the cosign note are
linked so other users may easily see relevant information from
both.
[0043] A delete note function allows the user to delete the pending
note. The user may not delete another user's notes nor may the user
delete a note once it has been accepted; however, it may be
possible to soft delete a note. There may be an occasion that a
note should be deleted, for example, if the note is out of date or
in error. In some instances, governmental regulations may prohibit
deleting of information from the patient's record. Soft deleting
allows the user to indicate the deleted status of the note while
not permanently removing the note from the system.
[0044] A filter function allows the user to modify the types of
notes that appear in the notes listing window and opens a filter
options window 72 shown in FIG. 6. There are many possible filter
criteria that may be implemented. For example, notes may be
filtered by time, author type, author, medical service, etc. For
example, selecting to filter by author type causes a listing of the
various author types 74 to appear in the filter options window 72.
The user selects a particular author type, such as physician,
registered nurse, etc., and after the user accepts the criteria,
the notes for that author type are displayed in the listing window
32.
[0045] A "my last note" function causes the user's most recent note
in the category to be highlighted. A search function opens a find
window (not depicted), in which the user may enter specific words
or phrases as criteria to search within the existing notes. The
search may be limited to a category of notes, or may encompass
multiple categories or all notes.
[0046] A legend/notes function toggles the notes listing window 32
between a notes state and legend state. In the notes state,
displayed within the listing window 32 is a listing of the filtered
notes for the current patient in reverse chronology order. In the
legend state, displayed within the listing window 32 is a key
explaining the symbols and colors associated with the notes. As
described above, to distinguish notes, by type, author or
otherwise, the notes may be displayed in corresponding colors
and/or may include a graphic representation, e.g., an icon,
adjacent the note to designate, for example, its author type, and
the legend state permits viewing of this representative
information.
[0047] A refresh function updates the information displayed in the
notes listing window 32. If other users have written notes for the
current patient since the last refresh, these new notes will now
appear in the listing window 32. If a filter option has been
selected, the listing is refreshed using the current filter
criteria. In addition, the information displayed in the notes
listing window 32 may periodically be updated at a rate specified
by a system administrator and/or by the user.
[0048] A print function causes the selected note to be printed. As
an option, the user may select to print all of the notes by
selecting an all notes function associated with the print
button.
[0049] Referring now to FIGS. 7-15, and initially to FIG. 7,
workflows associated with the operation of the system 10 are
described in greater detail. Workflow 700 begins with a logged in
user opening an available patient record, 701. The system 10 checks
the user's security record for authorized activities, and displays
the authorized activities in the activity bar 28, 703. If the user
is not authorized to view patient notes, 705, then the notes option
is not made available to the user via the activity bar 28, 707.
Otherwise, the user selects the patient's notes activity from the
activity bar 28, 709, and the system checks the user's security to
determine the notes the user may access, 711, and these notes are
displayed in the listing window 32, 713. The user may then add,
edit, filter, search, cosign, etc. notes by selecting such
functions from the appropriate one of the notes toolbar, 715, the
notes listing window, 717 or the notes display window, 719. Links,
721-741, take the user to a workflow corresponding to the selected
activity.
[0050] From link 721 for the new/edit/delete functions, the
workflow 700 proceeds to the workflow 800 illustrated in FIG. 8. If
the user wants to delete a note, 801, the user selects the note to
be deleted and clicks a Delete button, 803. The system 10 updates
the notes listing, removing the deleted note from all tabs on which
it was displayed, 805. If the user wants to edit a note, 807, the
users selects an Edit Note button opening the new/edit note window
56, 811. Similarly, if the user wants to create a note, 809, the
user selects a New Note button opening the new/edit note window 56,
811. The user has several options for creating/editing a patient
note, as described above. Once the note is created/edited, the user
clicks a Pend button to close the new/edit note window 56 and save
the note under a pending notes tab. Notes that have not been
accepted may be saved under the pending notes tab of the new/edit
notes window 56. Other users may not view pending notes and the
user may edit or delete the note until it has been accepted. If the
user wants to accept the note, the user clicks an Accept button to
close the new/edit notes window 56 and save the note. Once the note
is accepted, it cannot be edited and may only be soft deleted.
There is also a Cancel button allowing the user to cancel out of
the new/edit notes window without saving changes.
[0051] From the link 723 for the note addendum function, the
workflow 700 proceeds to the workflow 900 illustrated in FIG. 9. If
the user wants to create an addendum to a note, the user selects
the note and selects the addendum function opening the new/edit
note window 56, 901. Because a note cannot be edited and only may
be soft deleted once accepted, adding an addendum provides for
adding or updating note information. Editing of the addendum is the
same as that for editing or creating a note, except that the
original text of the note may not be edited, 903. When completed,
the user accepts the addendum, and the new addended version of the
note appears in the notes listing window 32 with a date and time
stamp link to the original note, 905.
[0052] From the link 725 for the note filter function or the link
737 for the note filter tab, the workflow 700 proceeds to the
workflow 1000 illustrated in FIG. 10. If the user selects the
filter tab, 1001, from the notes listing window 32, the system 10
updates the notes listing to include only those notes associated
with the category indicated on the selected tab in reverse
chronological order, 1003. If the user selects the filter button,
1001, the filter window 72 is opened, 1005, allowing the user to
set filter criteria, 1007. Filter criteria includes, but is not
limited to, filter by time, filter by author type, all notes,
unselect all, reload filter preferences, save filter preferences,
accept or cancel. Filter by time options include filtering by time
periods such as the previous 24 or 48 hours, since last note entry
or all notes. The select all allows the user to select all author
types, and the unselect all allows the user to unselect all author
types. The user may create preferred filter configurations, and
these preferences may be saved in connection with the user profile.
This permits the user to easily filter and view the notes most
commonly associated with their work activity. Accepting the filter
selections returns the user to the notes window 29.
[0053] From the link 727 for the "my last note" function, the
workflow 700 proceeds to the workflow 1100 illustrated in FIG. 11.
If the user selects the "my last note" button, 1101, the system 10
automatically highlights the most recent note authored by the user,
1103. The notes listing is scrolled as necessary to permit display
of the user's last note.
[0054] From the link 729 for the search function, the workflow 700
proceeds to the workflow 1200 illustrated in FIG. 12. If the user
selects the search button, 1201, a find window (not depicted) is
opened, 1203. Within the find window, the user may set search
criteria, 1205. The search criteria may include text that is to be
whole or partial word searched within the text of the notes,
including matching case. The search direction can be set between
chronological in ascending or descending order. Once a note meeting
the criteria is found, it is highlighted in the notes listing
window 32. Using a next button, the user may move to the next note
meeting the search criteria. To exit the search function, the user
presses a cancel button.
[0055] From the link 731 for the legend/notes function, the
workflow 700 proceeds to the workflow 1300 illustrated in FIG. 13.
If the user selects the refresh button, 1301, the system 10
refreshes the listing of notes in the notes listing window 32,
1303. If the user selects the time mark button, 1305, all notes
displayed for the patient are marked as viewed by the user as of
that current date and time. This time mark data is stored within
the system 10, and is available for use in conjunction with
decision support tools (e.g., has an urgent note regarding the
patient been reviewed within the last 24 hour period). If the user
selects the legend button, 1309, the notes listing in the notes
listing window 32 is replaced with a legend showing the symbols
associated with each author type, 1311. When the user selects the
notes button, 1313, the notes listing window 32 toggles back to the
notes listing, 1315.
[0056] From the link 735 for the notes listing column function, the
workflow 700 proceeds to the workflow 1400 illustrated in FIG. 14.
Upon selecting the notes listing column function, the notes listing
in the notes listing window 32 is re-sorted in ascending or
descending order on the basis of the information listed in the
selected column, 1401. Sorting is in alphabetical or numerical
order depending on the type of information in the column. The user
can click the column again to reverse the sort order from ascending
to descending, or vice versa.
[0057] From the link 739 for the cosign function, the workflow 700
proceeds to the workflow 1500 illustrated in FIG. 15. Upon
selecting the cosign required button for a note in the notes
viewing pane, 1501, the cosign note window 66 is opened. Fields
within the cosign note window 66 includes note type box indicating
the type of note being cosigned, a note text box displaying the
note text along with additional information including the author
and the data and time the note was filed, and cosign text box
allowing the cosigning user to enter text in connection with
cosigning the note, 1503.
[0058] From the link 733 for the print function and the link 741
for the copy function, the workflow proceeds to the workflow 1600
illustrated in FIG. 16. Upon selecting the copy button for a note
from the notes viewing window 34, 1601, the text of the note is
copied onto a clipboard, such as the Windows clipboard, 1603. From
the clipboard the text may be copied to other notes or may be
copied to other applications. Upon selecting the print button for a
note from the notes viewing window 34, 1605, the text of the
selected note is printed through an appropriately configured
printer along with any other information listed with the note in
the note viewing window 34, 1607. Types of other information
include author and author type.
[0059] The invention has been described in terms of several
embodiments, including a number of features and functions. Not all
features and functions are required for every embodiment of the
invention, and in this manner the invention provides a flexible
system by which a user may document and use clinical patient
information. The features discussed herein are intended to be
illustrative of those features that may be implemented; however,
such features should not be considered exhaustive of all possible
features that may be implemented in a system configured in
accordance with the embodiments of the invention.
* * * * *