Integrated system for generation and retention of medical records

Abstract

A system for populating patient records by use of evidence-based relational database, which compares the medical practitioners diagnoses to predetermined responses, to produce accurate patient chart notes and the integration of stored and generated data into clinical and administrative medical record keeping and billing. Episodic encounters are developed into cases for a specific patient under the care of a practitioner. The subjective symptoms from the patient and the objective observations of the care provider concurrent with the episode are used to form a diagnosis which presents a treatment regimen from an evidence-based relational database and populates medical and administrative templates. Patient history and updated information are retained in the database. “Best practice” treatment plans are continuality placed in the relational database from practice guides and experts in the field.

What is claimed is: 
     
         1 . An automated method for generating medical records including chart notes, comprising the steps of:
 (a) diagnosing a patient based upon objective observations and/or subjective symptoms;   (b) entering said diagnosis into a relational database, which correlates diagnosis to symptoms to populate medical records including a patient chart.   
     
     
         2 . The method of  claim 1  wherein said diagnosis generates a treatment regimen. 
     
     
         3 . The method of  claim 2  wherein said treatment regimen includes best practices. 
     
     
         4 . The method of  claim 2  wherein said treatment regimen is evidence based. 
     
     
         5 . The method of  claim 1  wherein said medical records include a super bill. 
     
     
         6 . The method of  claim 1  wherein said relational database includes statistical evaluation of efficacy of treatment regimens. 
     
     
         7 . The method of  claim 1  wherein said relational database includes evidence based best practices treatment regimens. 
     
     
         8 . The method of  claim 1  wherein said relational database includes expert based treatment regimens. 
     
     
         9 . A system for populating patient records by use of evidence-based relational database, which compares the medical practitioners diagnoses to predetermined responses, to produce accurate patient chart notes and the integration of stored and generated data into clinical and administrative medical record keeping and billing. 
     
     
         10 . The system of  claim 9  wherein said diagnoses additionally generates a treatment regimen. 
     
     
         11 . The system of  claim 10  wherein said treatment regimen includes best practices. 
     
     
         12 . The system of  claim 10  wherein said treatment regimen is evidence based. 
     
     
         13 . The system of  claim 9  wherein said relational database comprises a medical knowledge base, a patient treatment repository, a claims history repository, and practice management repository. 
     
     
         14 . The system of  claim 9  wherein said detailed chart note is generated from the raw treatment data and prior stored medical data based upon the physician's diagnosis by mapping prior patient information, diagnosis, treatments, and findings, as a grouped set with context sensitivity to a dictionary of descriptors. 
     
     
         15 . The system of  claim 14  further comprising a language processor to ensure that the descriptors are grammatically correct. 
     
     
         16 . The system of  claim 9  further comprising a report generator to populate a template with information from said relational data base that corresponds to the medical practitioner's diagnoses. 
     
     
         17 . The system of  claim 16  wherein said template is selected from a group consisting of Initial Patient Visits, Follow up Visits, Surgical Consultations, Pre-op H & Ps, Surgical Reports, Follow up Surgical Reports, and combinations thereof. 
     
     
         18 . The system of  claim 16  wherein said template is selected from a group consisting of a super bill, an invoice, an insurance claim and combinations thereof. 
     
     
         19 . The system of  claim 9  further comprising an anatomy reference view to assist in making the medical practitioners diagnoses. 
     
     
         20 . The system of  claim 9  wherein relational data base is used to assemble outcome studies.