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.

1 . A system for recording patient notes by a clinician, the system comprising:
 a server comprising:   a database;   an input module constructed to receive data input from a user,   a display module to display notes and note options; 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 from 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.   
     
     
         2 . The system of  claim 1  wherein the notes and note options are medical domain specific. 
     
     
         3 . The system of  claim 1  wherein current input from a user modifies subsequent notes and note options automatically generated by the adaptive notes generation module. 
     
     
         4 . The system of  claim 3  wherein clinician preferences learned by the adaptive notes generation module modifies the notes and note options automatically generated by the adaptive notes generation module. 
     
     
         5 . The system of  claim 4  wherein the frequency of clinician use of a clinical preference determines the clinician preferences automatically generated by the system. 
     
     
         6 . The system of  claim 1  further comprising at least one of a billing module, a prescription module, and a lab module. 
     
     
         7 . The system of  claim 1  further comprising a client computer system in communication with the server input module and the server display module. 
     
     
         8 . The system of  claim 7  wherein the client computer system is keyboardless. 
     
     
         9 . The system of  claim 8  wherein the input module and the display module are in communication and permit input from the client computer system using a graphical display. 
     
     
         10 . The system of  claim 9  wherein the graphical display produces graphical changes by rollover. 
     
     
         11 . The system of  claim 1  wherein the system automatically generates a treatment plan in response to input data and database data. 
     
     
         12 . The system of  claim 11  wherein the treatment plan is modifiable by a clinician. 
     
     
         13 . A method of recording patient notes by a clinician, the method comprising the steps of:
 providing an input screen on a computer system;   inputting data to the computer system;   accessing a database on the computer system 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.   
     
     
         14 . The method of  claim 13  further comprising the step of modifying the generation of domain specific notes and note options in response to subsequent input. 
     
     
         15 . The method of  claim 14  wherein the step of modifying notes and note options in response to subsequent input further comprises modifying notes and note options in response to clinician preferences. 
     
     
         16 . The method of  claim 15  wherein the notes and note options are modified in response to a clinician preference according to frequency of clinician use. 
     
     
         17 . The method of  claim 1  further comprising automatically generating a treatment plan in response to the data input and the patient data on the database. 
     
     
         18 . The method of  claim 17  wherein the treatment plan is modifiable by a user. 
     
     
         19 . The method of  claim 1  wherein the data input by a user is entered in response a prompt generated in response to metadata associated with an output graphic. 
     
     
         20 . A medium comprising an executable program, the executable program comprising the steps of:
 providing an input screen on a computer system;   inputting data to the computer system;   accessing a database on the computer system 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.