| 摘要 |
A system, method and computer program for electronic documentation of information, such as medical information, on problem-specific templates that can be validated, in real-time, for completeness The invention allows the user to organize, display, validate, archive, and export medical documentation on problem-specific templates By use of a recording device such as a digital pen, the invention combines the speed, ease of use, and familiarity of pen on paper with the data capture, real-time documentation validation, and real¬ time best practice prompts of traditional EMR systems Interactive chart validation can be performed at will, rather than the traditional method of medical quality assurance, which consisted of chart review after for the patient had been cared for and discharged The invention automatically tabulates the number of pre-specified fields with documentation and provides validation to ensure that each documented template has met the pre-specified documentation requirements, documentation suggestions and best health practices guideline prompts
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