Software device to facilitate creation of medical records, medical letters, and medical information for billing purposes

Abstract

A method is described which simplifies, automates and organizes the creation of notes and correspondence and also, by performing the calculations needed to determine the appropriate billing codes, provides documentation for billing purposes. It also assists the health care worker in determining the proper billing code. An embodiment of this to facilitate the creation of documents in the setting of patient care is described. The use of this for medical records is particularly of importance because of recent government (Heath Care and Finance Administration, or HCFA) regulations. The embodiment also allows one to enter information into a patient database at the same time that one is entering clinical information for the purposes of clinical care documentation. The database could be for clinical care, quality assurance, or research purposes. The embodiment describes how this can be achieved at the time that a service is delivered, for example when a health care worker sees a patient. Because the data is entered at the time of service, time is saved, and the information is more accurate. Although the embodiment describes a use in health care, this could be used in any industry. The invention allows one to enter information about patients using a combination of checklists, menus, and fill in the blank formats. The invention could use any handheld or desktop computer. Data entry also could be accomplished using scanner-enabled paper forms similar to those used by questionnaires or by tests such as the Scholastic Aptitude Test, with the user filling in the appropriate circles or other spaces to indicate the answer.