Records

The Problem Oriented Record Writer is a word processing software application developed to use speech recognition as the primary input method. Progress note and comprehensive note creation, and prescription writing are the main outcomes of the speech dictation data entry. A report writer, able to integrate all of the information entered into the database, enables a user to design printouts, or output files, suited to their individual needs.

The system will printout, or screen display, layman information, and expert/professional information on dictated problems. Problems and associated classification codes, like the ICDM codes for medical diagnoses, can be linked with procedures and their procedure codes, to produce billing data, directly from the information and coding imbedded in the database. Notes are saved and organized in reverse chronologic order.

Updated problems, and their previously entries, are saved and accessible in the database. A summary screen of the latest problem entry, along with a linked problem section, is displayed on a single screen, showing for example an active problem and order list. A list of previous problem entries and their linked sections are also viewable. From here many of the program features can be accessed. Adding new problems, or updating and editing a previously dictated problem, is quick and easy. Previously entered text can be readily incorporated into a new note.

Once a note section is dictated it can be used for a myriad of purposes. It can be printed or viewed in a prescription or note. Since all the text is searchable, and can be selected and embedded in all kinds of letters and documents, reports can be screen displayed or hard copy printed like: blood pressure and pulse rate lists, chronologic sigmoidoscopy results, work excuses, physician referrals, imaging orders, hospital orders with allergies and medications, jury duty letters, form letters. After each section is dictated, a complete note can be printed, or stored in the computer, in several predefined styles, or in a style and format of a user's creation. Form letters and reports incorporating demographic and dictated information, can be produced and edited.

Standardized forms for problems can be created and utilized. Then only the additions, or specific segments, need to be edited; instead of producing the full report, each time a typical problem requires dictation. For example, medical problems like sinusitis, bronchitis, or routine physical examinations, can have fill in templates.

In user selected dictation segments, every dictated word can be compared to a user defined table of word associations. For example, in a medical therapy section, dictating the word Penicillin, can cause a popup list of text choices, associated with Penicillin, to appear. Then any of the choices can be selected, to incorporate in the note. For example, one of the Penicillin choices can be 'Penicillin 250mg swallowed 4 times a day supply 10 days no refills', which when chosen is entered into the note, and can be printed as a prescription.

Some example layman and expert information sheets are supplied with the system, but an unlimited number can be added, to supply the user, or their client's, with viewable or printable information on a problem.

Although this program was designed for the medical care industry, any problem oriented record keeping endeavor could utilize it. The database can be configured for a wide variety of word processing applications. Although it takes time and effort to fully master a speech recognition program, and to fully master the versatility of this word processing program design, the resulting improvement in speed, ease of use, built in knowledge, make the training effort well worth while. Straight dictation and basic report printout are not very difficult, and can give a overview of the program's capability.

However, like any complicated device, it is the ability to add and utilize the other efficiencies, like tables, searches, templates, and more, which make the system, exceptional and eventually indispensable.