System and Method for the Recording of Patient Notes

A system for recording patient information by a user and automatically generating patient notes for a clinician, the system comprising:

• a server comprising:
• a database comprising clinician preference data, patient data, and metadata;
• an input module constructed to receive data input from the user and store it as patient data in the database;
• a display module to display notes, note options and reports;
• and
• an adaptive notes generation module in communication with the database, the input module and the display module, the adaptive notes generation module receiving input data from the user through the input module and provider preference data, patient data, and metadata from the database and in response to the input data from the input module and the clinician preference data, patient data, and metadata from the database, automatically generating a plurality of notes, note options, and reports using adaptive learning in response to clinician preference data, patient data, and metadata,
• wherein data is input and stored as objects that are interpretable by the adaptive notes generation module to generate a natural language structured display of the clinician's preferences in response to the metadata of each datum.

A method of recording patient information by a user and generating patient notes by an automated system for a clinician, the method comprising the steps of:

• providing an input screen on a computer system;
• inputting clinician preference data, patient data, and metadata to the computer system, wherein clinician preference data, patient data, and metadata is input and stored as objects that are interpretable by an adaptive notes generation module to enable a structured display of the clinician's preferences;
• accessing a database on the computer system to obtain patient data in response to data input to the input screen;
• and generating domain specific structured natural language notes, note options and reports in response to patient data, and past clinician preferences and metadata for each datum.