A
system and method for
processing patient data permits physicians and other
medical staff personnel to
record, accurately and precisely, historical
patient care information. An objective measure of a physician's rendered
level of care, as described by a clinical status code, is automatically generated. Data elements used in the determination of the generated clinical status code include a level of history of the patient, a level of examination of the patient, a decision-making process of the physician treating the patient, and a "time
influence factor." The quantity and quality of care information for a particular patient is enhanced allowing future care decisions for that patient to be based on a more complete
medical history. Enhanced care information can be used in outcome studies to track the
efficacy of specific treatment protocols. Archiving of
patient information is done in a manner which allows reconstruction of the qualitative aspects of provided medical services. The
medical care data can be recorded, saved, and transferred from a portable
system to a larger stationary information or
database system. Considerable physician and
staff time are saved and precision and accuracy are significantly enhanced, by generating these clinical status codes automatically (at the
point of service by the care-provider without any intermediary steps) from information recorded simultaneously with the provision of services.