System and Method for the Recording of Patient Notes

Abstract

A system and method for recording patient notes by a physician. In one embodiment, the system includes a server comprising: a database; an input module, a display module; and an adaptive notes generation module in the server in communication with the database, the input module and the display module, the adaptive notes generation module receiving input data from the input module and the database and in response to the input data from the input module and the database, automatically generating a plurality of notes and note options. In one embodiment, the method includes the steps of: providing an input screen; inputting data; accessing a database to obtain patient data in response to data input to the input screen; and generating domain specific notes and note options in response to patient data and input to the input screen.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS[0001]This application claims the benefit of U.S. Provisional Patent Application No. 61 / 370,250 filed Aug. 3, 2010, the entire disclosure of which is incorporated herein by reference.FIELD OF THE INVENTION[0002]The invention relates generally to the field of medical records and more specifically to the recordation of patient information.BACKGROUND OF THE INVENTION[0003]Studies have shown that physicians spend 45% of their time outside of the examination room. A good deal of that time is spent filling out paperwork, such as patient notes and billing documentation. It takes the average physician two minutes to dictate a note. Even computer-literate clinicians take four minutes to record a note using standard electronic medical records software. Therefore, the act of completing a patient record is time consuming.[0004]In addition to the patient health aspects of record keeping, record keeping also has an economic aspect. Payment depends in part on...

AI Technical Summary

Problems solved by technology

Therefore, the act of completing a patient record is time consuming.

Because of these complicated billing requirements, some physicians under-code their billing information.

Because these physicians are concerned that mistakes in billing entries might lead to an audit, these physicians will under-code or claim to have done less work than they what was actually performed to avoid missing something in the required documentation.

Conversely, physicians may mistakenly over-code.

The issue then is that note taking and diagnosis session related documentation by a physician is time consuming, fraught with errors and inefficient.

In general, these systems barely reduce the time it takes for a physician to enter a note into the medical record of a patient.

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