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.