Integrated system for generation and retention of medical records

• US 7,949,544 B2
• Filed: 01/03/2008
• Issued: 05/24/2011
• Est. Priority Date: 04/02/2003
• Status: Expired due to Fees

• Current Assignee: Starwriter, LLC
• Original Assignee: Starwriter, LLC
• Inventors: Miglietta, Joseph H., Ripperger, J Barton
• Primary Examiner(s): Gilligan; Luke
• Assistant Examiner(s): NGUYEN, TRAN N
• Application Number:
  US11/969,221
• Publication Number:
  US 20080103833A1
• Time in Patent Office: 1,237 Days
• Field of Search: 705/2
• US Class Current: 705/2
• 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. A computer based, method for managing, generating and updating an individual patient'"'"'s practice core database medical records to produce accurate chart notes, billing statements, and administrative records based upon a medical practitioner'"'"'s input of at least one episodic medical diagnoses, which can be anatomically directed, 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'"'"'s input of at least one episodic diagnoses generates from a relational database stored objective observations and/or subjective symptoms of a patient for updating said practice core database and populating detailed patient records and chart notes comprising the steps of;

(a) inputting at least one of the medical practitioner'"'"'s episodic diagnosis through a user interface into said relational database;

(b) generating within the relational database, based upon at least one of said medical practitioner'"'"'s input episodic diagnosis, an electronic correlation between said input episodic diagnosis and at least one practice related diagnoses ID, wherein each diagnoses ID contains;

i. stored general medical analysis, including an expected set of subjective symptoms predicted to be verbalized by a presenting patient, ii. a set of expected medical practitioner based observations; and

, iii. at least one treatment ID;

(c) displaying, on a display device, said 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 on an output device by transformation of said electronic correlation; and

, a set of correlated Treatment IDs;

(d) accepting at least one stored general medical analysis or part thereof; and

optionally accepting the Treatment IDs generated by the relational database in response to said input;

(e) integrating the accepted general medical analysis into the individual patient'"'"'s practice core database to update said individual patient'"'"'s practice core database;

(f) creating detailed patient records and chart notes by activating a user interface to automatically manage and update said individual patient'"'"'s clinical and administrative medical records.

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

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

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

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

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

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

8. The method of claim 1 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.

9. The method of claim 1 wherein said diagnosis is input through hand writing recognition, voice recognition, or typing.

10. An automated system for episodically managing, generating and updating an individual patient'"'"'s practice core database medical records to produce accurate chart notes, billing statements, and administrative records based upon a medical practitioner'"'"'s input of at least one episodic medical diagnoses, which can be anatomically directed, of the individual patient during an episode comprising:

(a) an electronic practice core database, stored on a medium, which contains an individual patient'"'"'s clinical and administrative medical records, including prior treatment regimens, historical documentation, chart notes; and

, billing information;

(b) at least one relational database, stored on a medium, which correlates at least one of said medical practitioner'"'"'s input episodic diagnosis to at least one practice related diagnoses ID, which 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; and

, at least one treatment ID;

(c) a database interface for inputting at least one of the medical practitioner'"'"'s at least one episodic diagnosis into said relational database to generate said correlated, stored general medical analysis for the practice related at least one diagnosis ID;

(d) a display for displaying to said medical practitioner, said correlated 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; and

, a set of correlated Treatment IDs;

(e) a user interface for accepting at least one stored general medical analysis or part thereof generated by the relational database in response to said input, and, integrating the accepted general medical analysis into the individual patient'"'"'s practice core database to update said individual patients practice core database; and

,

(f) a report generator for reading an updated individual patient'"'"'s practice core database to produce said individual patient'"'"'s clinical and administrative medical records.

11. The system of claim 10 wherein the relational database correlates said diagnosis ID to a set of treatment IDs associated with said diagnosis ID.

12. The system of claim 10 wherein said treatment ID'"'"'s data contain best practices.

13. The system of claim 10 wherein said treatment ID'"'"'s data are evidence based.

14. The system of claim 10 wherein said medical records include a super bill.

15. The system of claim 10 wherein said relational database includes data to aid in statistical evaluation of efficacy of treatment regimens.

16. The system of claim 10 wherein said treatment ID'"'"'s data includes expert based treatment regimens.

17. The system of claim 10 wherein said relational database comprises a medical knowledge base, a patient treatment repository, a claims history repository, and practice management repository.

18. The system of claim 10 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.

19. The system of claim 10 further comprising a security protocol that prevents unauthorized users from viewing sensitive patient medical history of treatment data.