Medical record forming and storing apparatus and medical record and method related to same

A medical record processing system comprising:

• a voice input device;
• a voice processor for receiving unprompted and unstructured free dictation from a medical personnel via the voice input device, for processing the dictation, and for generating voice data comprising a plurality of terms therefrom;
• a key term comparator for identifying a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms;
• a separator for separating the identified key medical terms from non-key medical terms in the generated voice data and for eliminating a non-key medical term from the generated voice data;
• a medical term matcher for matching the identified key medical term with a patient condition and for extracting from a knowledge database additional data on the patient condition;
• and
• a medical record creator for generating a draft medical record comprising the identified key medical term and the additional data.

A method for processing an orally delivered medical record comprising the steps of:

• receiving unprompted and unstructured free dictation from medical personnel;
• processing the dictation and generating voice data comprising a plurality of terms from the processed dictation;
• identifying a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms;
• separating the identified key medical terms from non-key medical terms in the generated voice data and eliminating a non-key medical term from the generated voice data;
• matching the identified key medical term with a patient condition and extracting from a knowledge database additional data on the patient condition;
• and
• generating a draft medical record comprising the identified key medical term and the additional data.

A medical record processing method comprising the steps of:

• inputting unprompted and unstructured free dictation from a medical personnel into a voice input device;
• receiving the dictation from the voice input device;
• processing the dictation and generating voice data comprising a plurality of terms therefrom;
• identifying a key medical term in the generated voice data by comparing each term in the generated voice data with a plurality of key medical terms;
• separating the identified key medical terms from non-key medical terms in the generated voice data and eliminating a non-key medical term from the generated voice data;
• matching the identified key medical term with a patient condition and extracting from a knowledge database additional data on the patient condition;
• and
• generating a draft medical record comprising the identified key medical term and the additional data.