Patent ID: 7233906

Claim:
A computer implemented method of creating a “baselet” for use in patient medical charts in a Clinical Information System (CIS), a “baselet” being a Progress Note (PN) in which coded elements from a knowledge base are pre-coordinated into a documentation template, the method comprising the steps of: accessing a library of baselets from a CIS database and creating an entry in the library for a new baselet; prompting via an input screen a care giver to input subjective information (S), objective data (0), an assessment (A), and a treatment plan (P) information into the baselet in a non-fixed format without storing the SOAP information in any individual patient medical chart in the CIS; prompting via an input screen the care giver to designate individual terms in the baselet as being in either a “positive”, a “negative” or an “off” state; and storing the baselet, with all its terms and term state information, in the baselet library of a computer-based CIS; and editing or creating versions of the baselet for charting episodes of health care based on state of the stored baselet.