Systems, methods and computer program products for creating and maintaining electronic medical records

Abstract

Systems, methods, and computer program products that generate electronic clinical medical records from patient encounters are provided. An illness for a particular patient is entered into a data processing system via an input device. Next, a defined retrievable clinical lexicon for that illness is displayed via the input device. The defined retrievable clinical lexicon comprises words and phrases associated with the illness. After the lexicon is displayed, a subset of words and phrases is selected from the lexicon for that patient encounter. A clinical medical record is then generated from the selected subset of words and phrases. A clinical medical record may be stored with like records for that patient and other patients, and associated with demographic records, fiscal records, drug administration records and the like for the patient. The collection of clinical records so created may be readily searched due to the enhanced uniformity of the records so created.