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 an improved patient specific record for at least one specific anatomic region, the system comprising:
 a processor;   a non-transitory computer readable medium coupled to the processor;   a graphical user interface configured to receive a gesture;   a display wherein a user can view at least one specific anatomic region representative of a patient;
 wherein the non-transitory computer readable medium stores machine executable instructions executable by the processor, the machine executable instructions configured to:
 display the graphical user interface with a patient image, wherein the patient image includes the anatomic region of the patient; 
 overlay an image or map over the patient image, wherein the overlaid image or map is aligned over the patient image using a plurality of landmarks; 
 match corresponding features of the patient image to the overlaid image or map; 
 receive input from the user wherein the input is a gesture wherein the gesture identifies specific patient information representative of a selected procedure, diagnosis, treatment, observation or documentation identified or created by the user; 
 retrieve from 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 wherein said templates each identify an input of a unique event or location attribute; 
 select an associated one of the plurality of templates according to each of the selected event and a location on the displayed representative anatomic region; 
 populate the set of fields associated with the selected template, at least one of the set of fields comprising text describing the selected event and the location on the displayed representative anatomic region; 
 fill at least one of the set of fields with the patient image associated with the anatomic region of the patient; 
 link the selected template and input to form a combined record; 
 generate a label for the combined record listing at least the anatomic region, a name of the patient, and a medical record number; 
 format the combined record into a database record suitable for an electronic health records database associated with the system; and 
 display the overlaid image or map over the patient image, and a complete patient history of the anatomic region, based on user identified or created events. 
 
   
     
     
         2 . The system of  claim 1 , the machine executable instructions further comprising a billing generation engine configured to create at least one multimedia item that includes a billing code. 
     
     
         3 . The system of  claim 1 , the machine executable instructions, when executed by the processor, further cause the processor to detect changes over time in a series of additional multimedia items. 
     
     
         4 . The system of  claim 3 , wherein the graphical user interface is configured to allow the user to select an anatomic region to receive a timeline associated with the anatomic region. 
     
     
         5 . The system of  claim 1 , wherein an image is at least one of various multimedia types including video, digital slide, document, photograph, two-dimensional graphic, three dimensional graphic, or vector model. 
     
     
         6 . A method for recording medical information of a specific anatomic region comprising:
 displaying, on a graphical user interface, a patient image, wherein the patient image includes the anatomic region of a patient;   overlaying an image or map over the patient image, wherein the overlaid image or map is aligned over the patient image using a plurality of landmarks;   matching corresponding features of the patient image to the overlaid image or map;   receiving input from the user wherein the input is a gesture wherein the gesture identifies information representative of a selected procedure, diagnosis, treatment, observation or documentation identified or created by the user;   retrieving from 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 wherein said templates each identify an input of a unique event or location attribute;   selecting an associated one of the plurality of templates according to each of the selected event and a location on the displayed representative anatomic region;   populating the set of fields associated with the selected template, at least one of the set of fields comprising text describing the selected event and the location on the displayed representative anatomic region;   filling at least one of the set of fields with the patient image associated with the anatomic region of the patient;   linking the selected template and input to form a combined record;   generating a label for the combined record listing at least the anatomic region, a name of the patient, and a medical record number;   formatting the combined record into a database record suitable for an electronic health records database associated with the method; and   displaying the overlaid image or map over the patient image, and a complete patient history of the anatomic region, based on user identified or created events.   
     
     
         7 . The method of  claim 6 , further comprising creating at least one multimedia item that includes a billing code. 
     
     
         8 . The method of  claim 6 , further comprising detecting changes in the additional multimedia items associated with the anatomic region of the patient that are taken over time. 
     
     
         9 . The method of  claim 6 , further comprising selecting an anatomic region to receive a timeline associated with the anatomic region. 
     
     
         10 . The method of  claim 6 , wherein an image is at least one of various multimedia types including video, digital slide, document, photograph, two-dimensional graphic, three dimensional graphic, or vector model.