Importance

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Abstract

An electronic system and a method for efficiently documenting medical findings that consist of both a problem and a location on or in the body. This invention further provides a method for documenting multiple problems in related body locations. This invention further provides a method for efficiently issuing orders associated with medical findings that consist of both a problem and a location on or in the body. The invention is able to enhance efficiency during the Physical exam making the invention an essential component of the physician's practice workflow. This, in turn, will enable the invention to serve as a single point of integration for a vast array of useful electronic tools and information. For example, in a computer-implemented system and method for documenting one or more medical findings having a body location and a type of medical finding, the method includes the steps of: displaying a body location selection view for a user, the user selecting a body location, the system then displaying a means of selecting possible types of medical findings, the system also then displaying a means of selecting to display a more detailed body location selection view, wherein the user selecting a type of medical finding causes the system to store a finding comprising the user-selected location and problem, and wherein the user selecting to display a more detailed body location selection view causes the system to display a more detailed body location selection view. The method may further include the finding types that may be selected are of a group of finding types and further comprising a means for selecting a different group of finding types to be displayed. Moreover, the groups of finding types each may correspond to a set of finding types related to one system of the body. The system may include a means for selecting one or more appropriate procedures that may be performed at the selected body location and a means for recording an annotation regarding the selected location of the body. The means for recording an annotation may be selected from a group including selecting a pre-generated annotation, recording a text annotation, recording a graphical annotation, recording a sound annotation, and recording a photographic annotation.

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First Claim