INTEGRATED SYSTEM FOR GENERATION AND RETENTION OF MEDICAL RECORDS

摘要

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 continuality placed in the relational database from practice guides and experts in the field.

主权项

1. An automated method for generating medical records including chart notes, comprising the steps of:
(a) diagnosing a patient based upon objective observations and/or subjective symptoms; (b) entering said diagnosis into a relational database, which correlates diagnosis to symptoms to populate medical records including a patient chart.