Abstract: A method is described which simplifies, automates and organizes the creation of notes and correspondence and also, by performing the calculations needed to determine the appropriate billing codes, provides documentation for billing purposes. It also assists the health care worker in determining the proper billing code. An embodiment of this to facilitate the creation of documents in the setting of patient care is described. The use of this for medical records is particularly of importance because of recent government (Heath Care and Finance Administration, or HCFA) regulations. The embodiment also allows one to enter information into a patient database at the same time that one is entering clinical information for the purposes of clinical care documentation. The database could be for clinical care, quality assurance, or research purposes. The embodiment describes how this can be achieved at the time that a service is delivered, for example when a health care worker sees a patient.