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Electronic Charting is meant to replace the paper SOAP format and Transcription. The process is workflow oriented and is very intuitive and consistent with what a provider currently does on a day-to-day basis. Through a series of question and answers on a portable wireless computer tablet, which requires no typing, you may quickly and accurately document what services have been performed. These Q&A's are commonly known as "Clinical Pathways" or "Decision Trees" and are customizable by specialty. They create all the necessary documentation to support HCFA and HIPAA requirements.
- Standard SOAP Format which is both intuitive and flexible
- Review patient medical history on-screen
- Implements practice guidelines / protocols by end-users
- Customizable Clinical Pathways / Decision Trees by specialty
- Presents contractual requirements at point-of-care
- Influences physician decision making
- Conditional Clinical Alerts
- Health Maintenance Alerts
- User-defined clinical queries
- Scanning images & documents (IDs, MRIs, lab results, pictures, etc.)
- Draw on diagrams presented on the screen
- Document progress notes via: Clinical Pathways, voice recording, handwritten notes or typed notes
- Voice messages attached directly to patient chart
- Record voice for transcription
- Automatic E&M level of service coding to maximize billing and reduce liability
- Billing initiated directly out of charting to eliminate superbills
- Central Clinical Repository to eliminate multiple charts and to allow simultaneous access by multiple sites and multiple users
- Data Analysis - Outcomes Analysis
- Referral letters
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