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.

What is claimed is: 
     
         1 - 20 . (canceled) 
     
     
         21 . 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. 
   
     
     
         22 . The system of  claim 21  wherein the notes and note options are medical domain specific. 
     
     
         23 . The system of  claim 21  wherein current input from a user modifies subsequent notes and note options automatically generated by the adaptive notes generation module. 
     
     
         24 . The system of  claim 23  wherein past clinician preferences learned by the adaptive notes generation module modifies the notes and note options automatically generated by the adaptive notes generation module. 
     
     
         25 . The system of  claim 24  wherein the frequency of clinician use of a past clinical preference determines the clinician preferences automatically generated by the system. 
     
     
         26 . The system of  claim 21  further comprising at least one of a billing module, a prescription module, and a lab module. 
     
     
         27 . The system of  claim 21  further comprising a client computer system in communication with the server input module and the server display module. 
     
     
         28 . The system of  claim 27  wherein the client computer system is keyboardless. 
     
     
         29 . The system of  claim 28  wherein the input module and the display module are in communication and permit input from the client computer system using a graphical display. 
     
     
         30 . The system of  claim 29  wherein the graphical display produces graphical changes by rollover. 
     
     
         31 . The system of  claim 21  wherein the system automatically generates a treatment plan in response to input data and database clinician preference data, patient data, and metadata. 
     
     
         32 . The system of  claim 31  wherein the treatment plan is modifiable by a clinician. 
     
     
         33 . 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. 
     
     
         34 . The method of  claim 33  further comprising the step of modifying the generation of domain specific notes and note options in response to subsequent input. 
     
     
         35 . The method of  claim 34  wherein the step of modifying notes and note options in response to subsequent input further comprises modifying notes and note options in response to past clinician preferences. 
     
     
         36 . The method of  claim 35  wherein the notes and note options are modified in response to a spat clinician preference according to frequency of clinician use. 
     
     
         37 . The method of  claim 21  further comprising automatically generating a treatment plan in response to the data input and the patient data on the database. 
     
     
         38 . The method of  claim 37  wherein the treatment plan is modifiable by a user. 
     
     
         39 . The method of  claim 21  wherein the data input by a user is entered in response a prompt generated in response to metadata associated with an output graphic. 
     
     
         40 . The system of claim  2 l wherein the adaptive notes generation module determines what metadata is necessary for the adaptive notes generation module to perform its function and if that metadata is missing, notifies the clinician as to the problem. 
     
     
         41 . The system of claim  2 l wherein the adaptive notes generation module determines what graphical user interface to use in response to patient data. 
     
     
         42 . The system of claim  2 l wherein the adaptive notes generation module determines what drug to prescribe in response to patient data. 
     
     
         43 . The system of  claim 21  wherein the adaptive notes generation module generates a plurality of entry options as a hierarchy of clinician preferences and determines a hierarchy by a response to a previous entry in the hierarchy.