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US 7,461,079 B2Granted
Patient encounter electronic medical record system, method, and computer product
OwnerThomas M. Walker, Mark Maddeninventors
Life of this patent
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Abstract
A patient encounter electronic medical record system, method, and computer product includes pre-populated, diagnosis specific templates, selective, specialty-specific master databases, and anatomic specific databases and templates to achieve comprehensive, accurate and compliant medical documentation that captures patient data concurrently with the clinical patient encounter session. The system is enabled for a distributed computing environment including graphical user interfaces and voice, text, and digital image and x-ray input.
Claims36
A patient encounter electronic medical record apparatus comprising:
- a processor;
- an interface configured to receive data input by a physician and an output interface coupled to said processor;
- a memory;
- and
- a plurality of diagnosis specific pre-populated templates stored in said memory and accessible by said processor, default entries in said diagnosis specific pre-populated templates being changeable to alternate values by said physician, said default entries being associated with a pre-determined diagnosis, wherein
- said interface is configured to receive an input of a diagnosis entered by said physician, and, in response to the entered diagnosis, the interface is configured to output one or a plurality of said diagnosis specific pre-populated templates that correspond with the diagnosis entered by the physician,
- said processor is configured to produce an electronic medical record from said output one said diagnosis specific pre-populated templates,
- said diagnosis specific pre-populated templates being configured to enable said physician to perform said diagnosis in at least one of an office setting, a surgery setting, an analgesic setting, and a therapy setting, wherein
- said diagnosis specific pre-populated templates are derived at least one of a selective specialty specific database and an anatomic specific database, and
- wherein said diagnosis specific pre-populated templates are end-user modifiable.
7 more elements
A patient encounter electronic medical record apparatus comprising:
- a processor;
- inputting means for receiving data input by a physician and outputting means for
- outputting data, said inputting means and said outputting means coupled to said processor;
- memory means for storing data;
- and
- a plurality of diagnosis specific pre-populated template means for structuring data stored in said memory means and accesible by said processor means, default entries in said diagnosis specific pre-populated template means being changeable to alternate values by said physician, said default entries being associated with a predetermined diagnosis;
- wherein
- said inputting means is configured to receive an input of a diagnosis entered by said physician, and, in response to the diagnosis, the inputting means is configured to output one or a plurality of said diagnosis specific pre-populated template means that correspond with the diagnosis entered by the physician,
- said processor produces an electronic medical record from said output of said diagnosis specific pre-populated template means,
- said diagnosis specific pre-populated template means being configured to enable said physician to perform said diagnosis in at least one of an office setting, a surgery, an analgesic setting, and a therapy setting, wherein
- said diagnosis specific pre-populated template means are derived from at least one of a selective specialty specific database an anatomic specific database, and
- wherein said diagnosis specific pre-populated template means are end-user modifiable.
9 more elements
A patient encounter electronic medical record computer product comprising:
- a processor;
- an interface configured to receive data input by a physician and an output interface coupled to said processor;
- a memory configured to hold computer-readable instructions;
- and
- a plurality of diagnosis specific pre-populated templates stored in said memory and accessible by said processor, default entries in said diagnosis specific pre-populated templates being changeable to alternate values by said physician, said default entries being associated with a predetermined diagnosis, wherein
- said interface is configured to receive an input of a diagnosis entered by said physician, and, in response to the entered diagnosis, the interface is configured to output one or a plurality of said diagnosis specific pre-populated templates that correspond with the diagnosis entered by the physician,
- and wherein said processor is configured to produce an electronic medical record from said output of said diagnosis specific pre-populated templates,
- said diagnosis specific pre-populated templates being configured to enable said physician to perform said diagnosis in at least one of an office setting, a surgery setting, an analgesics setting, and a therapy setting, wherein
- said diagnosis specific pre-populated templates are derived from at least one of a selective specialty specific database and an anatomic specific database, and
- wherein said diagnosis specific pre-populated templates are end-user modifiable.
7 more elements
A method for recording a patient encounter electronic medical record, comprising the steps of:
- holding a plurality of diagnosis specific pre-populated templates with default entries in a memory accessible by a processor;
- making a diagnosis by a physician;
- entering the diagnosis made by the physician into the processor;
- retrieving a subset of the plurality of diagnosis specific pre-populated templates that correspond with the diagnosis made by the physician, said retrieving step being performed after said step of entering the diagnosis;
- verifying said default entries and changing as necessary said default entries in said subset of the diagnosis specific pre-populated templates by a physician input;
- and
- producing an electronic medical record from said subset of diagnosis specific pre-populated templates and entries associated therewith, after said verifying step, wherein
- said diagnosis specific pre-populated templates being configured to enable said physician to perform said diagnosis in at least one of an office setting, a surgery setting, an analgesics setting, and a therapy setting, wherein
- said diagnosis specific pre-populated templates are derived from at least one of a selective specialty specific database and an anatomic specific database, and
- wherein said diagnosis specific pre-populated templates are end-user modifiable.
7 more elements
Dependencies are inferred from the claim text.