Patient encounter electronic medical record system, method, and computer product
First Claim
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1. A patient encounter electronic medical record apparatus comprising:
- a processor;
an input interface configured to receive data input by a physician and an output interface coupled to said processor;
a memory; and
a plurality of diagnosis specific pre-populated templates stored in said memory and accessible by said processor, default entries in said diagnosis specific pre-populated templates being changeable to alternate values by said physician, said default entries being associated with a pre-determined diagnosis;
wherein said user interface is configured to receive an input by said physician to select a subset of said diagnosis specific pre-populated templates that correspond with a diagnosis made by the physician and said processor is configured to produce an electronic medical record from said subset of diagnosis specific pre-populated templates.
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Abstract
A patient encounter electronic medical record system, method, and computer product includes pre-populated, diagnosis specific templates, selective, specialty-specific master databases, and anatomic specific databases and templates to achieve comprehensive, accurate and compliant medical documentation that captures patient data concurrently with the clinical patient encounter session. The system is enabled for a distributed computing environment including graphical user interfaces and voice, text, and digital image and x-ray input.
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Citations
43 Claims
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1. A patient encounter electronic medical record apparatus comprising:
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a processor;
an input interface configured to receive data input by a physician and an output interface coupled to said processor;
a memory; and
a plurality of diagnosis specific pre-populated templates stored in said memory and accessible by said processor, default entries in said diagnosis specific pre-populated templates being changeable to alternate values by said physician, said default entries being associated with a pre-determined diagnosis;
wherein said user interface is configured to receive an input by said physician to select a subset of said diagnosis specific pre-populated templates that correspond with a diagnosis made by the physician and said processor is configured to produce an electronic medical record from said subset of diagnosis specific pre-populated templates. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39)
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14. A patient encounter electronic medical record apparatus comprising:
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a processor;
inputting means for receiving data input by a physician and outputting means for outputting data, said inputting means and said outputting means coupled to said processor;
memory means for storing data; and
a plurality of diagnosis specific pre-populated template means for structuring data stored in said memory means and accessible by said processor means, default entries in said diagnosis specific pre-populated template means being changeable to alternate values by said '"'"'physician, said default entries being associated with a predetermined diagnosis;
wherein said inputting means is configured to receive an input by said physician to select a subset of said diagnosis specific pre-populated template means that correspond with a diagnosis made by the physician and said processor produces an electronic medical record from said plurality of diagnosis specific pre-populated template means.
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27. A patient encounter electronic medical record computer product comprising:
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a processor;
an input interface configured to receive data input by a physician and an output interface coupled to said processor;
a memory; and
a plurality of diagnosis specific pre-populated templates stored in said memory and accessible by said processor, default entries in said diagnosis specific pre-populated templates being changeable to alternate values by said physician, said default entries being associated with a predetermined diagnosis;
wherein said user interface is configured to receive an input by said physician to select a subset of said diagnosis specific pre-populated templates that correspond with a diagnosis made by the physician, and wherein said processor is configured to produce an electronic medical record from said subset of diagnosis specific pre-populated templates.
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40. A method for recording a patient encounter electronic medical record, comprising the steps of:
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holding a plurality of diagnosis specific pre-populated templates with default entries in a memory and accessible by a processor;
making a diagnosis by a physician;
retrieving a subset of the plurality of diagnosis specific pre-populated templates that correspond with the diagnosis made by the physician;
verifying said default entries and changing as necessary said default entries in said subset of the diagnosis specific pre-populated templates by a physician input; and
producing an electronic medical record from said subset of diagnosis specific pre- populated templates and entries associated therewith, after said verifying step. - View Dependent Claims (41, 42, 43)
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Specification