INTEGRATED SYSTEM FOR GENERATION AND RETENTION OF MEDICAL RECORDS

• US 20080103833A1
• Filed: 01/03/2008
• Published: 05/01/2008
• Est. Priority Date: 04/02/2003
• Status: Active Grant

• Current Assignee: Starwriter, LLC
• Original Assignee: Starwriter, LLC
• Inventors: Ripperger, J., Miglietta, Joseph
• Granted Patent: US 7,949,544 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 20/00 ICT specially adapted for therapies or health-improving plans, e.g. for handling prescriptions, for steering therapy or for monitoring patient compliance
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 70/60 relating to pathologies

Abstract

A system for populating patient records by use of evidence-based relational database, which compares the medical practitioners diagnoses to predetermined responses, to produce accurate patient chart notes and the integration of stored and generated data into clinical and administrative medical record keeping and billing. Episodic encounters are developed into cases for a specific patient under the care of a practitioner. The subjective symptoms from the patient and the objective observations of the care provider concurrent with the episode are used to form a diagnosis which presents a treatment regimen from an evidence-based relational database and populates medical and administrative templates. Patient history and updated information are retained in the database. “Best practice” treatment plans are continually placed in the relational database from practice guides and experts in the field.

Claims

1. (canceled)

22. The method of claim 1 wherein the relational database correlates said diagnosis ID to a set of treatment IDs associated with said diagnosis ID.

23. The method of claim 1 wherein said treatment ID'"'"'s data contain best practices.

24. The method of claim 1 wherein said treatment ID'"'"'s data are evidence based.

25. The method of claim 1 wherein said medical records include a super bill.

26. The method of claim 1 wherein said relational database includes data to aid in statistical evaluation of efficacy of treatment regimens.

27. The method of claim 1 wherein said treatment ID'"'"'s data includes expert based treatment regimens.

2. (canceled)

3. (canceled)

4. (canceled)

5. (canceled)

6. (canceled)

7. (canceled)

8. (canceled)

9. (canceled)

10. (canceled)

11. (canceled)

12. (canceled)

13. (canceled)

14. (canceled)

15. (canceled)

16. (canceled)

17. (canceled)

18. (canceled)

19. (canceled)

20. (canceled)

21. An automated method for managing, generating and updating an individual patient'"'"'s practice core database medical records based upon a medical practitioner'"'"'s at least one episodic medical diagnoses of the individual patient wherein said practice core database contains an individual patient'"'"'s clinical and administrative medical records, including prior treatment regimens, historical documentation, chart notes;

and, billing information, and wherein the medical practitioner makes said at least one episodic diagnoses from objective observations and/or subjective symptoms of the patient gathered during said episode comprising the steps of;

(a) generating a relational database, which relational database correlates to at least one practice related diagnoses ID, uniquely based upon at least one of said medical practitioner'"'"'s episodic diagnosis, to at least one treatment ID wherein each treatment ID contains stored general medical analysis, including an expected set of subjective symptoms predicted to be verbalized by a presenting patient, as well as a set of expected medical practitioner based observations;

(b) inputting at least one of the medical practitioner'"'"'s at least one episodic diagnosis into said relational database to generate said stored general analysis for the related at least one treatment ID;

(b) accepting at least one stored general analysis or part thereof generated by the relational database in response to said input;

(c) integrating the accepted general analysis into the individual patient'"'"'s practice core database to update said individual patient'"'"'s practice core database thus automatically managing and updating said individual patient'"'"'s clinical and administrative medical records.

28. An automated system for episodically managing, generating and updating an individual patient'"'"'s practice core database medical records based upon a medical practitioners at least one episodic medical diagnoses of the individual patient wherein said practice core database contains an individual patient'"'"'s clinical and administrative medical records including prior treatment regimens, historical documentation, chart notes;

and, billing information, and wherein the medical practitioner makes said at least one episodic diagnoses of the individual patient from objective observations and/or subjective symptoms of the individual patient gathered during said episode comprising;

(a) at least one relational database, which relational database correlates at least one practice related diagnoses ID, uniquely based upon at least one of said individual patient'"'"'s episodic diagnosis, to at least one treatment ID wherein each treatment ID contains stored general medical analysis including an expected set of subjective symptoms predicted to be verbalized by a presenting patient, as well as a set of expected medical practitioner based observations;

(b) means for inputting at least one of the medical practitioners at least one episodic diagnosis into said relational database to generate said stored general analysis for the related at least one treatment ID;

(b) means for accepting at least one stored general analysis or part thereof generated by the relational database in response to said input;

(c) means for integrating the accepted general analysis into the individual patient'"'"'s practice core database to update said individual patients practice core database thus automatically managing and updating said individual patient'"'"'s clinical and administrative medical records.

29. The system of claim 28 wherein the relational database correlates said diagnosis ID to a set of treatment IDs associated with said diagnosis ID.

30. The system of claim 28 wherein said treatment ID'"'"'s data contain best practices.

31. The system of claim 28 wherein said treatment ID'"'"'s data are evidence based.

32. The system of claim 28 wherein said medical records include a super bill.

33. The system of claim 28 wherein said relational database includes data to aid in statistical evaluation of efficacy of treatment regimens.

34. The system of claim 28 wherein said treatment ID'"'"'s data includes expert based treatment regimens.

35. A computerized system for populating individual patient records by use of evidence-based relational database, which compares the medical practitioners episodic diagnoses based upon objective observations and/or subjective symptoms of the individual patient gathered during said episode using to predetermined expected individual patent responses for updating the individual patient'"'"'s medical records, to produce accurate patient chart notes and the integration of stored and generated data into clinical and administrative medical record keeping and billing.

36. The system of claim 35 wherein said diagnoses additionally generates an expected treatment regimen to populate individual patient'"'"'s practice core database.

37. The system of claim 35 wherein said treatment regimen includes best practices.

38. The system of claim 35 wherein said relational database comprises a medical knowledge base, a patient treatment repository, a claims history repository, and practice management repository.

39. The system of claim 35 wherein said detailed chart note is generated from the raw treatment data and prior stored medical data based upon the physician'"'"'s diagnosis by mapping prior patient information, diagnosis, treatments, and findings, as a grouped set with context sensitivity to a dictionary of descriptors.

40. The system of claim 35 further comprising a report generator to populate a template with information from said relational database that corresponds to the medical practitioner'"'"'s episodic diagnoses of the individual patient.