Improved systems and methods for collecting
Protected Health Information (PHI) with or without the assistance of a physician scribe are described. Documenting a
patient encounter utilizing a template-based charting
system (either electronic or paper-based), and the tracking of this
document status and patient clinical status throughout the encounter, for purposes of managing multiple patients and multiple patients' documents, as well as improved communication between providers and assistants. The systems and methods of this invention generally comprise an
electronic records system for creating and maintaining information in
electronic records;
patient tracking system (either computerized or not) for managing tasks specific to provider
documentation of specific
clinical care actions and patient clinical status; complimentary utilization of
medical history questionnaires which are designed to correlate with template-based charting tools; methods of communication between provider assistants (including physician assistants, nurses, secretaries, scribes, patients, or other assistants) to convey the status of the collection and management of the PHI, including patient history,
patient examination, testing results,
medical decision making, patient disposition plan, follow-up information and other elements of provider charting of PHI; sequence of
patient tracking indicators that represent steps in the care of the patient, status of the document, and clinical or
documentation-related tasks for completion by providers or provider assistants; improvements on a real-time compliance system for identifying the specific stage or status of each electronic
record, and allowing providers and assistants to track this
completion status, thereby streamlining
documentation and compliance workflows.