| 摘要 |
Improved systems and methods for collecting Protected Health Information (PHI) with or without the assistance of a physician scribe are described. Documenting a patient encounter utilizing a template-based charting system (either electronic or paper-based), and the tracking of this document status and patient clinical status throughout the encounter, for purposes of managing multiple patients and multiple patients' documents, as well as improved communication between providers and assistants. The systems and methods of this invention generally comprise an electronic records system for creating and maintaining information in electronic records; patient tracking system (either computerized or not) for managing tasks specific to provider documentation of specific clinical care actions and patient clinical status; complimentary utilization of medical history questionnaires which are designed to correlate with template-based charting tools; methods of communication between provider assistants (including physician assistants, nurses, secretaries, scribes, patients, or other assistants) to convey the status of the collection and management of the PHI, including patient history, patient examination, testing results, medical decision making, patient disposition plan, follow-up information and other elements of provider charting of PHI; sequence of patient tracking indicators that represent steps in the care of the patient, status of the document, and clinical or documentation-related tasks for completion by providers or provider assistants; improvements on a real-time compliance system for identifying the specific stage or status of each electronic record, and allowing providers and assistants to track this completion status, thereby streamlining documentation and compliance workflows.
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