Importance

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Abstract

An integrated medical software system with embedded transcription functionality is disclosed. The system comprises a clinical module for capturing clinical data for a patient in a first electronic document and a communication component that communicates the clinical data to a rule-based clinical decision support (CDS) system and receives at least one of an alert, warning, reminder, and recommendation back from the CDS system based on the clinical data. The CDS system is configured to compare the clinical data against a knowledge base to identify the at least one of an alert, warning, reminder, and recommendation; the clinical data is serialized into a standardized database language and placed into a first electronic clinical document defined by a clinical document exchange standard before being communicated to the CDS system; and the at least one of an alert, warning, reminder, and recommendation is provided in a second electronic clinical document defined by the clinical document exchange standard when received back from the CDS system.

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First Claim