Patent ID: 7853446

Claim:
A method for generating a codified electronic record using a computer comprising an output device, the method comprising: receiving, within the computer, a textual commentary from a clinician, wherein the clinician is a source of the textual commentary; responsive to receiving the textual commentary from the clinician, and in real time, analyzing the textual commentary to identify a plurality of codes that potentially correlate to the textual commentary, wherein analyzing the textual commentary comprises: maintaining a code acceptance history of identified codes previously accepted by the clinician on a per clinician basis, wherein within the code acceptance history, each code is correlated with an attribute identified within the textual commentary; and selecting the plurality of codes, at least in part, according to the code acceptance history, wherein one or more identified codes previously accepted by the clinician and correlated to a particular textual commentary attribute are selected when the textual commentary corresponding to the particular textual commentary attribute is received and analyzed; presenting the identified codes to the clinician through the output device; responsive to presenting the identified codes, receiving a first clinician input selecting at least one of the identified codes presented via the output device; and adding the selected code to the electronic record responsive to receiving the first clinician input.