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System and method for remotely inputting and retrieving records and generating reportsRelated Patent Categories: Data Processing: Database And File Management Or Data Structures, Database Or File Accessing, Distributed Or Remote AccessSystem and method for remotely inputting and retrieving records and generating reports description/claimsThe Patent Description & Claims data below is from USPTO Patent Application 20060212452, System and method for remotely inputting and retrieving records and generating reports. Brief Patent Description - Full Patent Description - Patent Application Claims
BACKGROUND OF THE INVENTION [0001] 1. Technical Field [0002] The present invention relates to an electronic storage and retrieval system and method for remotely inputting data and records and for generating reports; specifically, an electronic storage and retrieval system and method for facilitating interactive computer and dictation input of data and records and to automatically generate reports. [0003] 2. Discussion of Related Art [0004] It has been the practice of professionals, such as doctors, lawyers, and engineers to personally record pertinent information on a subject patient, client, or matter so that professional services performed and data pertinent to the subject are documented. The documented information can be in many different forms, such as a patient database with patient demographic and clinical data, an engineer's report on the structural conditions of a building, or an invoice for professional services performed. In many instances, the professional memorializes the pertinent data contemporaneously as services are performed, such as by handwritten notes or by dictation into a voice recorder, and the information is subsequently gathered for an office staff personnel to enter into a report. Many reports are standardized as forms and the gathered information is filled into the form for efficient reporting. For example, in the case of a physician examining a patient, clinical information for a patient is developed during discussions with and the physical examination of a patient. The physician makes dictation or writes the clinical information observed during the examination and the forms and notes are typically later entered by a medical staff in the physician's office. Likewise, an engineer may be inspecting a building and dictates his observations on the conditions of the building and a building inspection report can be generated by filling in a form-like report with standard pre-filled text on general building condition, supplemented by contemporaneous information using the recorded dictation. [0005] In the case of patient information and report, a patient is typically required to complete a questionnaire which discloses personal information about a patient, including background medical information and pre-existing medical conditions. The questionnaire may also establish a patient's current medical condition. A patient's history file is opened and contains the completed questionnaire along with other documents. [0006] As part of the physical examination, the physician makes a determination as to the medical condition of a patient and this is generally referred to as the patient diagnosis. Also, the physician makes a determination as to how a diagnosed medical condition is to be treated medically and this is generally referred to as a patient treatment plan. The information derived from the examination is also referred to as clinical information. [0007] When a patient is examined by a physician, the results of the physical examination or clinical information are typically recorded by the physician entering the information manually onto a form which is then placed in the patient's history file. Also, it is common practice for the healthcare professional to make hand notes during the patient's physical examination. The hand notes are later used by the physician for personally dictating a patient's report. The dictation is then transcribed, reviewed and signed by the physician who conducted the patient's physical examination. [0008] The practice of dictating and transcribing is widely used to record information in the medical and other fields. Physicians have been increasingly burdened by the need to document every encounter with patients. Physicians must record information about each patient's office visit, diagnosis, suggested treatment and prescription given. In addition to recording patient's information, physicians must fill out forms for submission to insurance companies and provide information to regulatory agencies. Physicians spend a significant portion of their work day gathering and dictating the needed information for each record or form. Further, a physician must maintain a staff to transcribe the information into reports and fill out required forms. [0009] Additionally, as many medical offices operating under health maintenance organization (HMO) oversight are required to audit the examination notes of medical professionals for consistency and trends in diagnosis and treatment, the lack of computerized databases for monitoring and updating clinical examination data and the time consuming process of re-transcribing and editing paper charts into a computer database can complicate this auditing process. [0010] There are a number of medical history documentation systems known in the art which are intended to more efficiently and effectively gather and/or document medical information of a patient. Some examples of medical documentation systems are provided below. [0011] U.S. Pat. No. 4,428,733 discloses an information gathering system used for obtaining medical information from a patient. The system has one or more question sheets bearing a set of questions, usually medical questions written in the language of the patient. A separate answer sheet is provided, upon which the patient provides answers the questions. The answer sheet has information concerning each possible answer. A mechanism is preferably provided for positioning and holding the answer sheet in a predetermined position relative to the question sheets to enable the patient to see the information on the answer sheet as well as the questions. [0012] U.S. Pat. No. 3,913,118 discloses a process and apparatus for accurately recording medical and personal information obtained from a medical patient or a prescription customer. This process and apparatus expedited accounting and bookkeeping procedures related to the medical treatment or transcription services furnished the patient or customer. A transparent matrix has pre-printed thereon in permanent ink portion of a form for recording information to be submitted for payment to a medical program for professional services rendered to the patient or member of the program. The matrix also includes a means forming a pocket thereon for receiving and holding an identification card or other information bearing form, such as a prescription order or the like. [0013] U.S. Pat. No. 4,991,091 discloses a self-contained apparatus used personally by a physician during patient examination. The apparatus is battery operated and can be programmed to alter or modify examination information or produce a permanent record of examination results. The apparatus includes a pen board which includes microprocessor based controller with internal memory having prestored thereon sets of specific examination indicia which are displayed by liquid crystal displays ("LCDs"). The patient's name is displayed on an LCD. Associated with the specific examination indicia are one or more light emitting diodes ("LEDs") and corresponding bar codes which represent permanently pre-printed indicia representations. [0014] General information diagnosis categories are identified by suitable words such as "Vital Signs". Also, LEDs and bar codes are provided for general examination and treatment categories such as, for example, "Chemistry Profile." The bar codes are used with a light pen for optically identifying the corresponding category and the LED adjacent to each category indicia are illuminated for indicating the category selected by the physician. The controller includes suitable memory for storing patient examination information, for controlled programming of the operating panel and for down loading data to a central computer. A light pen provides input to a microcontroller to manipulate scanning in one or more bar code panels. The concept is based on the examining physician personally using the pen board, light pen and microprocessor during the examination procedure to record medical information. [0015] U.S. Pat. No. 5,267,155 describes a document generation system which automates the documentation process in the medical field. The system provides a computer-based documentation system incorporating a retrievable database with a menu driver and graphic window environment. The documentation system utilizes previously defined document templates or "boiler-plates" to manage Patient Reports and includes user interface for use in selecting phrases to be inserted in the template. [0016] The system contemplates that the physician personally conducts a patient examination and either generates personal notes which the physician can use later for dictation or the physician personally fills out a checklist. In this manner, the physician reports of the patient examination can vary for each patient. The input for the report is prepared directly by the physician and can contain any number of variable responses. Each variable response may include different options, such as options on a menu of a computer. The physician can then personally modify and customize the report document throughout by inserting words into the generated document with the use of an integrated word processor. When the physician personally completes a checklist, another individual can generated the desired document from information checked off by the physician on the checklist. [0017] U.S. Pat. No. 6,026,363 discloses a medical history documentation system and method for recording information relating to at least one of a designed patient's current medical condition, a physical examination, a diagnosis and a treatment plan. The system includes a recording member having a plurality of discrete recording sections formed thereon programmed for recording information relating to the patient. The encoded indicia is communicated by a first person to a second person during a physical examination of the patient by the first person. An input member is used by the second person for recording medical information in the form of predetermined encoded indicia in applicable discrete recording sections of the recording member. A transcriber having a plurality of report section templates is used. Each report section template corresponds to a discrete recording section. Each of the report section templates comprise a plurality of optional text variable segment each of which are assigned to a selected one of the predetermined encoded indicia. The transcriber is operative to decode each one of the predetermined encoded indicia recorded on the recording member. An imaging device responsive to the transcriber prepares a patient's report specific to the designated patient. [0018] Despite the advances in the art, there is a need for a system and method for facilitating interactive dictation of data and records and to automatically generate reports. A need also exists for a system and method of managing medical records for concurrently recording patient history and/or examination notes, if so desired, during patient examination. A further need exists to have a system and method of managing medical records in which the physician may document (e.g., by dictating or transcribing) the medical information by voice dictation over a global electronic network. [0019] It is an aspect of the present invention to provide a comprehensive system and method of managing records, such as medical records, in which the system, through a voice driven, voice entry interactive mechanism, facilitates the medical professional to input information and to generate a report. [0020] It is another aspect of the present invention to provide a system and method for managing medical records through a computer program that provides for specific pre-encoded indicia of medical information, such as medical codes, basis for billing, symptoms, standard phrases and templates that are physician specific. [0021] It is another aspect of the present invention to provide for a system and method for managing medical records in which the computer program used provides for patient specific data. [0022] It is another aspect of the present invention to provide for a system and method for managing medical records in which the computer program provides a basis for editorial using voice input. [0023] It is another aspect of the present invention to provide for a system and method for managing medical records in which the system associated therewith provides a basis for generating reports and in various desirable forms. 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