Patent ID: 8321241

Claim:
A medical records information apparatus for use with a networked database storing data of patients in electronic patient records, comprising: (a) a computing device having a processor and a machine readable medium containing machine readable code for performing a computer implemented method and executable by the processor of the computing device, (b) wherein the computing device is configured for network communications with the networked database for accessing data from and storing data in the networked database, and (c) wherein the computer implemented method comprises the steps of, (i) providing a user interface including, (A) one or more user interface areas configured to allow for creation of a structured note representing clinical documentation of a patient, and (B) one or more user interface areas configured to allow for selection, during the creation of the structured note, of one or more categories of medical data for which data associated with patients is stored in the networked database, (ii) receiving, via the user interface provided in said step (i), a selection of one or more of the categories of medical data, (iii) accessing data that has been previously stored in the networked database, that is associated with a patient for which a structured note representing clinical documentation is being created, and that corresponds to the one or more categories of medical data of the selection of said step (ii), (iv) presenting, during the creation of the structured note via the user interface, the data accessed from the networked database in said step (iii), (v) receiving, via the user interface provided in step (i), input for creating the structured note, the structured note including medical information associated with the one or more categories of medical data of the selection of said step (ii), (vi) in response to user input, storing in the networked database the structured note as a part of a clinical documentation stored in the electronic patient record of the patient, and (vii) in conjunction with the storing of the structured note in said step (vi), automatically storing in the networked database, as a part of the electronic patient record of the patient, information from the structured note in a second area of the electronic patient record, the second area being determined based on predetermined system administrator settings and the one or more categories of medical data of the selection of said step (ii).