Method and apparatus for performing patient documentation

Abstract

This invention provides a hospital patient documentation method and apparatus which is used to generate an initial patient health plan which identifies the patient's health problems, the causes of the problems, expected outcomes, and interventions to achieve such outcomes. The system also provides for the periodic entry of progress notes on the patient, with the system automatically updating the care plan for the patient in response to the progress notes. The initial care plan and all updates are stored so that a audit trail is maintained and the user may obtain either a current patient health plan or a historical patient health plan on demand. The system is menu driven to facilitate uniformity and menu items are coded to facilitate subsequent retrieval and processing. Outcomes are displayed with outcome due dates and progress note generation may be inhibited if, on an outcome due date, the outcome has not been achieved or the due date updated.