| 摘要 |
A hospital documentation system that allows for the electronic capture of data for patient forms. The electronic forms constitute a medical record for the patient. The record is stored and is available electronically to users throughout the institution, both on site and off site as long as a connection to the institution's network is available. Hospital coders review the documentation concurrent with the patient being within the hospital, and can submit queries to the physician, the results of which are also forms captured electronically within the medical record that may be reviewed by the hospital coders. The medical record is used in addition to other systems by the coders to perform hospital coding on the patient case, and ultimately to generate hospital bills and claims for the patient.
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