Medical examination and transcription method, and associated apparatus

A method for generating a compliant patient record that is compliant with insurance guidelines, the method comprising:

• providing a medical transcription system that includes a plurality of fields that may be filled with either a default value or a non-default value;
• providing a template for a doctor to view the default values for each one of said plurality of fields, the default values for each one of said plurality of fields may vary based on an exam level;
• dictating the non-default values for each one of said plurality of fields where the default value is inappropriate;
• inputting the non-default values, and allowing the medical transcription system to input the default values, in the medical transcription system;
• and
• generating the compliant patient record.

A method for generating a compliant patient record that is compliant with insurance guidelines, in which a doctor relies on a template to view the default values for each one of a plurality of fields, the default values for each one of said plurality of fields may vary based on an exam level, the doctor dictating the non-default values for each one of said plurality of fields where the default value is inappropriate, the method comprising:

• providing a medical transcription system that includes the plurality of fields that may be filled with either a default value or a non-default value, the default values for each one of said plurality of fields may vary based on an exam level;
• inputting the non-default values, and allowing the medical transcription system to input the default values, in the medical transcription system;
• and
• generating the compliant patient record.

An apparatus for generating a patient record that is compliant with insurance guidelines, the insurance guidelines including a plurality of service levels associated with patient care wherein each of the different service levels affords a health care provider a different amount of reimbursement, the apparatus comprising:

• means for receiving answers to a patient intake questionnaire;
• means for determining a service level applicable to a patient encounter by applying objective rules to the questionnaire answers, wherein the objective rules identify a service level that maximizes the amount of reimbursement associated with the patient encounter;
• means for applying the determined service to a medical treatment template in order to identify elements of service to be provided to the patient during the encounter;
• means for providing the identified elements of service to the patient during the encounter;
• means for documenting the identified elements of service provided to the patient following the encounter;
• and
• means for forming the compliant patient record by inputting reimbursement information documented by said means for documenting into a computer system, wherein the reimbursement information corresponding to the patient encounter is only inputted into the computer system after at least the means for receiving answers, means for determining a service level applicable, and the means for applying the determined service to a medical treatment template have completed their respective functions.

An apparatus for generating a compliant patient record that is compliant with insurance guidelines, the apparatus comprising:

• means for providing a medical transcription system that includes a plurality of fields that may be filled with either a default value or a non-default value;
• means for providing a template for a doctor to view the default values for each one of said plurality of fields, the default values for each one of said plurality of fields may vary based on an exam level;
• means for dictating the non-default values for each one of said plurality of fields where the default value is inappropriate;
• means for inputting the non-default values, and allowing the medical transcription system to input the default values, in the medical transcription system;
• and
• means for generating the compliant patient record.

A method for generating a compliant patient record that is compliant with insurance guidelines, the method comprising:

• filling in a plurality of fields of a medical transcription system that may be filled with either a default value or a non-default value;
• a doctor viewing the default values for each one of said plurality of fields in a template, the default values for each one of said plurality of fields may vary based on an exam level, wherein, using the template, a doctor can dictate the non-default values for each one of said plurality of fields where the default value is inappropriate;
• inputting the non-default values using a medical transcription system including a computer;
• allowing the medical transcription system to input the default values to be stored by the medical transcription system;
• and
• generating the compliant patient record using the medical transcription system.

A business method for generating a compliant patient record that is compliant with insurance guidelines, the method comprising:

• filling in a plurality of fields of a medical transcription system that may be filled with either a default value or a non-default value;
• a doctor viewing the default values for each one of said plurality of fields in a template, the default values for each one of said plurality of fields may vary based on an exam level, wherein, using the template, a doctor can dictate the non-default values for each one of said plurality of fields where the default value is inappropriate;
• inputting the non-default values using a medical transcription system including a computer;
• allowing the medical transcription system to input the default values to be stored by the medical transcription system;
• and
• generating the compliant patient record using the medical transcription system.

A method for generating a letter using a patient record that is compliant with insurance guidelines, the letter includes fields, the method comprising:

• filling in a plurality of fields of a medical transcription system that may be filled with either a default value or a non-default value;
• a doctor viewing the default values for each one of said plurality of fields in a template, the default values for each one of said plurality of fields may vary based on an exam level, wherein, using the template, a doctor can dictate the non-default values for each one of said plurality of fields where the default value is inappropriate;
• inputting the non-default values using a medical transcription system including a computer;
• allowing the medical transcription system to input the default values to be stored by the medical transcription system;
• generating the compliant patient record using the medical transcription system;
• applying the input default or non-default values into the fields of the letter;
• and
• generating the letter including the default fields.

A business method for generating a patient record that is compliant with insurance guidelines, the insurance guidelines including a plurality of service levels associated with patient care wherein each of the different service levels affords a health care provider a different amount of reimbursement, the method comprising the steps of:

• (A) receiving answers to a patient intake questionnaire;
• (B) determining a service level applicable to a patient encounter by applying objective rules to the questionnaire answers, wherein the objective rules identify a service level that maximizes the amount of reimbursement associated with the patient encounter;
• (C) applying the determined service to a medical treatment template in order to identify elements of service to be provided to the patient during the encounter;
• (D) providing the identified elements of service to the patient during the encounter;
• (E) after the encounter, documenting the identified elements of service provided to the patient;
• and
• (F) forming the compliant patient record by inputting reimbursement information documented in step (E) into a computer system, wherein the reimbursement information corresponding to the patient encounter is only inputted into the computer system after at least steps (A) to (C) have been performed.