Apparatus, method and software for developing electronic documentation of imaging modalities, other radiological findings and physical examinations

Abstract

A system for guiding a user's physical examination of a patient and for generating a transcript. The system comprises: a screen requesting patient identification information, wherein the patient identification information excludes a patient name and further requesting patient medical history information; a screen requesting vital signs information; a screen requesting selection of an anatomical region of the patient for examination, wherein the user selects an anatomical region responsive to the request; a screen providing a plurality of possible observed symptoms related to the selected anatomical region, wherein the user selects one or more of the possible observed symptoms; a screen presenting possible findings that may be observed during the physical examination, wherein the user selects one or more of the possible findings based on the physical examination and a screen displaying a patient transcript responsive to information entered into the previous screens.