Web-based Clinical Documentation Overview

Sophisticated web-based clinical documentation tool for daily progress notes, discharge summaries and instructions, clinic notes, telephone interactions and occurrence/incident reporting. Customizable, template-based documentation includes integration of patient lab, radiology and pharmacy information; configurable carry-forward of previous fields; routing and approval; direct upload to Meditech; auto-saving; and medical spell-checker.

Screenshots

Navigate to any previous documentation Navigate to any previous documentation

One click to start a history and physical One click to start a history and physical

Key fields are automatically brought forward Key sections are automatically brought forward from a previous day's note.

Documentation tempalte design is very flexible Documentation template design is very flexible

Lab results are be automatically imported from Meditech to the note Lab results are be automatically imported from Meditech directly into the note

Clinicians can select any additonal lab values to include Clinicians can select any additional lab values to include

Current Medications can be automatically imported from Meditech into the note Current medications can be automatically imported from Meditech into the note

Pre-built templates include 9 different QI/QA Occurence Reports Pre-built templates include 9 different QI/QA Occurrence Reports

All the fields and data needed to analyse sentinal events are included All the fields and data needed to analyze sentinel events are included

Occurence reports can be routed to all appropriate departments and indviudals and tracked in real-time. Occurrence reports can be routed to all appropriate departments and individuals and tracked in real-time.

Features & Benefits

Template-driven clinical documentation that is easy to complete and easy to communicate.

No need to re-type information from Meditech
Notes automatically import admissions, lab, and pharmacy results from Meditech with no re-typing and no chance for error.
Medical Spell Check
Built-in spell checker with medical dictionary
On-click uploading of documents to Meditech for e-signing
Any documents created can up uploaded to Meditech ITS/OE for e-signing as a dictated report.

Secure and trackable
Specific documentation types may be marked as hidden, read-only or editable by different user groups. Every action is logged and a complete audit trail viewable on-screen.
Auto-faxing
Documentation may be configured to auto-fax to PCP's, Pharmacy's or other providers when completed.
Auto-save
Every note is auto-saved every 30 seconds so users don't have to worry about web connectivity or session time-out issues.

Frequently Asked Questions

  • Can we build our own templates? Yes, you can build the templates in any HTML editor.
  • What hardware is required? A SQL server to store the data and a web server to host the website.