Method and system for generating a medical report and computer program product therefor

Abstract

A method and a system for generating, with the assistance of a computer system(), a medical report () suitable for automatic billing, wherein an electronic template () suited for a specific patient's condition is selected out of a plurality of given electronic templates stored in storage means (); personal data of the specific patient's and previously stored in storage means () are automatically entered into the selected electronic template; and medical report text passages and instructions are entered into the selected template by dictating and using a speech recognition system (); additionally, condition data are automatically entered on the basis of condition information as far as stored in storage means () into the selected template, and code data associated with these condition information are automatically embedded in the selected template; and when entering medical report text passages, at least one predetermined voice macro stored in storage means () together with code data embedded therein is called in; the code data thus embedded in the medical report () being applicable when coding the medical report for automatic billing.