ELECTRONIC HEALTH RECORD SYSTEM AND METHOD FOR PATIENT ENCOUNTER TRANSCRIPTION AND DOCUMENTATION

摘要

A patient encounter documentation and analytics system includes a mobile computing platform and a server-based host platform. A mobile application in tandem with a wireless microphone collects voice signals during a patient-caregiver encounter, transforms the voice signals into audio data files, and uploads the audio data files to the server. A speech recognition software module digitally transcribes the audio data file into text. A text processing module extracts and organizes relevant clinical data based on keyword, key phrase and question/answer analysis. Relevance of words and phrases may be determined in view of, e.g., their presence, frequency and context. A diagnostic decision support module enables the healthcare provider to review the determined clinical information and provide a diagnosis associated with the encounter. A documentation skeleton module extracts diagnosis-specific text components from the transcribed text file and assembles an electronic medical document based on the diagnosis and the diagnosis-specific text components.