Graphical generation and retrieval of medical records

Abstract

Systems and method are provided for generating a record of a medical procedure. A system includes a processor and a non-transitory computer readable medium. The medium includes a graphical user interface configured to display a graphic representing an anatomical region of a patient and accept a gesture from a user comprising a selected procedure and, diagnosis when appropriate, and a location on the displayed anatomical region. A knowledge base stores a plurality of templates, each comprising a set of fields. A record generation engine selects an associated one of the plurality of templates according to each of the selected procedure and, diagnosis when appropriate, and the location on the displayed anatomical region and populates the set of fields associated with the selected template. A database interface formats the populated template into a database record suitable for an electronic health records database associated with the system.

What is claimed is: 
     
         1 . A system for generating a record of a medical procedure comprising:
 a processor; and   a non-transitory computer readable medium, storing machine executable instructions executable by the processor, the machine executable instructions comprising:
 a graphical user interface configured to display a graphic representing an anatomical region of a patient and accept a gesture from a user comprising a selected procedure and a location on the displayed anatomical region; 
 a knowledge base storing a plurality of templates, each comprising a set of fields, with a first template of the plurality of templates having a different set of fields than a second template of the plurality of templates; 
 a record generation engine configured to select an associated one of the plurality of templates according to each of the selected procedure and the location on the displayed anatomical region and populate the set of fields associated with the selected template, at least one of the set of fields comprising text describing the selected procedure and the location on the displayed anatomical region; and 
 a database interface configured to format the populated template into a database record suitable for an electronic health records database associated with the system. 
   
     
     
         2 . The system of  claim 1 , the machine executable instructions further comprising a billing generation engine configured to aggregate a plurality of selected procedures and locations from the graphical user interface to represent a patient interaction, assign a billing value to each of a plurality of sets of at least one of the selected procedures according to the selected procedures and the associated locations, and generate a bill for the patient interaction. 
     
     
         3 . The system of  claim 1 , wherein the set of fields associated with the selected template comprises a total number of units of a substance associated with the procedure and a cost per unit for the substance, the billing generation engine being further configured to calculate a total price for the substance from the total units and the cost per unit. 
     
     
         4 . The system of  claim 1 , the record generation engine being configured to fill at least one of the set of fields with a first multimedia item associated with the anatomical region of the patient taken prior to the selected procedure and additional multimedia items associated with the anatomical region of the patient taken during and after the selected procedure. 
     
     
         5 . The system of  claim 4 , the record generation engine being further configured to generate a digital label overlaid over a portion of each multimedia item listing at least the anatomical region, a name of the patient, and a medical record number. 
     
     
         6 . The system of  claim 1 , further comprising a touchscreen display configured to allow the user to interact with the graphical user interface. 
     
     
         7 . The system of  claim 1 , wherein the selected procedure is a pharmaceutical administration of a specified number of units. 
     
     
         8 . The system of  claim 1 , wherein the selected procedure is a Mohs surgical procedure, the set of fields comprising at least a first photograph of the anatomical region of the patient taken prior to the Mohs surgical procedure, a second photograph of the anatomical region of the patient taken during the Mohs surgical procedure, and a third photograph of the anatomical region of the patient taken after the Mohs surgical procedure. 
     
     
         9 . The system of  claim 1 , further comprising a printer responsive to the record generation engine and configured to print a label including one or more of the anatomical region, a name of the patient, a date of birth of the patient, a differential diagnosis, a chronological specimen number, letter, or code; and a medical record number. 
     
     
         10 . The system of  claim 1 , wherein the graphical user interface is further configured to display a menu based on the selected procedure, the user selecting at least one parameter for the set of fields associated with the selected template from the menu. 
     
     
         11 . The system of  claim 10 , wherein the graphical user interface is further configured to display a first menu when a first procedure is selected and a second menu when a second procedure is selected, the first and second menus having different associated options based on the anatomic location, diagnosis, and proposed treatment. 
     
     
         12 . The system of  claim 1 , further comprising an image interface configured to process a received image of a supply label or patient identification label associated with the selected procedure and to extract at least one of the set of fields associated with the selected template from the received image. 
     
     
         13 . The system of  claim 1 , wherein the graphical user interface is configured to allow the user to select a location to receive a timeline of procedures and diagnoses associated with the location. 
     
     
         14 . A method for recording a medical procedure comprising:
 allowing a user to make a gesture on a specific location on a displayed graphic representing an anatomical region of a patient, the gesture representing a selected procedure performed at that location;   selecting one of a plurality of available templates according to each of the selected procedure and the specific location;   populating at least one of the set of fields associated with the selected template with text describing the selected procedure and the specific location; and   formatting the populated template into a database record suitable for an electronic health records database.   
     
     
         15 . The method of  claim 14 , further comprising filling at least one of the set of fields with a first multimedia item associated with the anatomical region of the patient taken prior to the selected procedure and additional multimedia items associated with the anatomical region of the patient taken during and after the selected procedure. 
     
     
         16 . The method of  claim 15 , further comprising generating a digital label overlaid over a portion of each multimedia item listing at least the anatomical region, a name of the patient, and a medical record number. 
     
     
         17 . The method of  claim 14 , further comprising:
 processing a received image of a product label associated with the selected procedure; and   extracting at least one of the set of fields associated with the selected template from the received image.   
     
     
         18 . A system for generating a record of a medical procedure comprising:
 a processor;   a camera; and   a non-transitory computer readable medium, storing machine executable instructions executable by the processor, the machine executable instructions comprising:
 a graphical user interface configured to display a graphic representing an anatomical region of a patient and accept a gesture from a user comprising a selected procedure and a location on the displayed anatomical region; 
 a knowledge base storing a plurality of templates, each comprising a set of fields, with a first template of the plurality of templates having a different set of fields than a second template of the plurality of templates; 
 a record generation engine configured to select an associated one of the plurality of templates according to each of the selected procedure and the location on the displayed anatomical region and populate the set of fields associated with the selected template, a first subset of at least one of the set of fields comprising text describing the selected procedure and the location on the displayed anatomical region and a second subset of at least one of the set of fields with a first photograph of the anatomical region of the patient taken by the camera prior to the selected procedure and additional photographs of the anatomical region of the patient taken by the camera during and after the selected procedure; and 
 a database interface configured to format the populated template into a database record suitable for an electronic health records database associated with the system. 
   
     
     
         19 . The system of  claim 18 , the machine executable instructions further comprising a billing generation engine configured to aggregate a plurality of selected procedures, diagnoses and locations from the graphical user interface to represent a patient interaction, assign a billing value to each of the selected procedures according to the selected procedures, diagnoses and the associated locations, and generate a bill for the patient interaction.