Transferring documentation onto the cloud - important things to know

Advantages of cloud-based clinical documentation system

Clinical documentation is a task that is required from all healthcare professionals. Finding ways to organize, record, and store your documentation whilst maintaining efficiency can be difficult for some practices. Fortunately, cloud-based technology offers various advantages when it comes to producing clinical documentation:

1. Real-time: Cloud-based systems update in real-time, ensuring that all healthcare providers have access to any changes in medical records instantly. These systems are also mobile-friendly, allowing information to be accessed from numerous devices.
2. Updates and maintenance: One of the best aspects of cloud-based technology is that updates and maintenance all happen internally. This means that your business doesn’t have to spend time fixing malfunctioning hard drives, and guarantees that you are consistently using the latest technology.
3. Security: Using a HIPAA-compliant system will guarantee that all of the data uploaded has various protective features. Only authorized users are able to access a client’s medical information, and the remote servers use sophisticated encryption and other protection tools.
4. Streamline documentation: Cloud-based technology allows physicians to boost the consistency of their notes by using various templates and documentation resources. With these tools, your practice can spend less time collating your clients’ clinical documentation, and more time actually seeing those clients!

Guidelines for clinical documentation

Although the specific content included within your documentation will depend on the services you offer and the field of healthcare that you work in, there are certain guidelines that are applicable to every healthcare professional:

1. Timely: Staying up to date in your clinical documentation is one of the most important factors. You should be writing your progress notes after every session with a client and making changes to medical records as soon as they arise.
2. Concise: Whilst it’s important to be thorough, excessively long documents make it extremely hard for other healthcare providers to extract important information. Be specific and use language that is easily understood.
3. Legible: This might seem obvious, but you would be surprised by how many practitioners write illegible notes! The easiest way around messy handwriting is to use an electronic system, but if you are determined to stick to the traditional method, make sure that your documentation is set out clearly and neatly.
4. Stay informed: Rules and regulations pertaining to clinical documentation and medical billing are constantly changing. It is always a good idea to use a clinical documentation sourcebook and hold staff meetings to discuss any applicable changes.

5 important things to know while transferring clinical documentation to the cloud

If you choose to implement a cloud-based system, there are a few things you need to know before you transfer all of your documentation to the cloud.

1. Business associate agreement: One of the biggest concerns surrounding cloud-based technology relates to the security of confidential information. HIPAA guidelines dictate that cloud service providers (CSPs) need to become business associates of your healthcare practice before you upload your data. Once you have entered your business associate agreement, then you are abiding by HIPAA guidelines and can store your data.
2. Do your research: Although a business associate agreement is required, this shouldn’t be your only step in identifying whether or not a remote server is appropriate. Cloud service providers will use different methods to guarantee security, and you should make sure the system you select has suitable protection features.
3. Integration: The best clinical documentation cloud-based systems are integrated with various other features designed to assist with the administrative tasks of your practice. These will differ but typically can include appointment scheduling systems, medical billing and coding features, a patient portal, and online payments.
4. Patient satisfaction: As the healthcare industry moved predominantly to a value-based model of care, it is becoming increasingly important to consider patient needs when implementing new systems. Patients often want to have access to their records, and a good cloud-based system should facilitate this. 
5. Physician satisfaction: When considering new technology for your healthcare practice, you must also think about the abilities of your staff. The whole point of using these systems is to streamline the clinical documentation process and make it easier for physicians. Having a confusing and complicated cloud-based system would completely negate this goal, as physicians who find it too difficult may revert back to traditional methods. You should choose a system that is easy to navigate and requires minimal technical skill so that everyone can become proficient. 

Adopt Carepatron's cloud-based clinical documentation system

Evidently, there are quite a few things you need to think about when choosing a cloud-based system for your healthcare practice! However, although this process may seem daunting, it shouldn’t really be that strenuous. The best way to guarantee clinical documentation improvement is by selecting the right system, and that’s where we can help. 

Carepatron offers a HIPAA-compliant platform that is perfect for a range of healthcare businesses. The system allows physicians to complete their clinical documentation efficiently and consistently by using a variety of note templates and helpful resources. Once they have been written, clinical documentation is stored in a highly secure manner. Carepatron takes privacy seriously, and all data undergoes bank-level encryption. Clinical documentation is accessible to authorized users at any time, from any device, helping improve effective communication and continuity of care. Carepatron also offers a highly useful speech-to-text tool that can streamline previously handwritten notes and save a lot of transcription time! 

Additionally, Carepatron is integrated with various other features designed to streamline the administrative side of your business, including medical billing, appointment scheduling, online payments, and secure video conferencing. With these features, your practice can optimize your efficiency and productivity, all whilst working on delivering the best quality of healthcare possible.

Take home message

Regardless of what field of healthcare you work in, cloud-based systems are becoming increasingly implemented into businesses. These systems are particularly useful for helping with clinical documentation, as they are designed to optimize both organization and efficiency. Additionally, most cloud-based systems are integrated with features that can help with other administrative tasks, saving your practice significant amounts of money and time. Embracing these new forms of technology can feel like a daunting move, but the extensive benefits will undeniably benefit both you and your patients!

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Further Reading:

• Patient data in the cloud‍
• Documenting general patient observations