Improve your clinical documentation

Maintaining effective clinical documentation is one of the most important aspects of working as a healthcare professional. Not only are they used to track the progress and treatment of a client, but they are important documents in both legal and insurance situations. It has been recorded that up to 70% of patient records contain wrong information, an alarming statistic that urgently needs to be rectified.
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Improve your clinical documentation

The Clinical Documentation Software you and your clients will love

Clinical appointment scheduling
Appointment Scheduling
Take control of your schedule and calendar from your desktop or mobile app. Use automated appointment reminders and our fully integrated video calling tool to maximize your productivity.
Clinical Notes and Clinical Documentation
Health Records
Store all your patient information, clinical notes, and documentation safely in your secure clinic system. We autosave, so you'll never lose work again.
Clinical billing and Clinical online payments
Accept Online Payment
Carepatron online or mobile payments make it easier for your clients to pay for your bills.  You save time a massive amount of time while getting paid twice as fast. What a great way to improve your day and cashflow!
Clinical documentation improvement with better practice management

Clinical documentation improvement with better practice management

Clinical documentation improvement (CDI) refers to the implementation of programs and processes specifically designed to elevate clinical notes and records. Making the decision to implement practice management software into your healthcare clinic is undoubtedly one of the most effective ways that businesses can improve their clinical documentation. Specifically, this improvement is facilitated by features that focus on the following:

EHR system: Good practice management software is integrated with a centralized EHR system that is intuitively laid out and easy to navigate. EHR systems use cloud-based technology, meaning that all uploaded data is accessible by authorized users at any time, from anywhere. Using EHR allows practitioners to be more consistent in the production and storage of their documentation, as all clinical notes, files, and records are kept in the same centralized location. 

Efficiency: We all know that writing clinical notes and maintaining good documentation is a comprehensive task that can be both time-consuming and overwhelming for practitioners. With practice management software, these processes are streamlined and practitioners can cut down on the amount of time they spend catching up on notes. Optimizing efficiency is the key to maintaining a successful business, and the time that is saved by using practice management systems can be redirected into completing other, more important tasks.

Going mobile: In the digital age that we are currently living in, the majority of people, practitioners, and patients alike, use mobile devices. Given the fast-paced nature of our lives, it is becoming increasingly important that certain healthcare services and tasks can be completed remotely - a process that is facilitated by practice management software. Practitioners are able to complete patient records and clinical notes and store them electronically using just their mobile device; helping everyone stay organized whilst on the go.

All your clinical documentation in one place

Carepatron offers highly sophisticated practice management software that is guaranteed to optimize the organization and efficiency of your healthcare business. With its intuitive layout, healthcare staff will become experts in no time, regardless of their technological skills. Some of the extensive features and associated benefits offered by Carepatron include:

Clinical notes: Carepatron includes a variety of clinical note templates, including SOAP and DAP, that will allow you to save a significant amount of time. These templates are fully customizable, allowing you to maintain some flexibility whilst still streamlining the documentation process. Carepatron’s clinical note templates will allow you to save time and improve the consistency of your documentation. 

Mobile-friendly: The software is integrated with a mobile-friendly app, allowing practitioners to maintain productivity even when they are on the move. With Carepatron’s mobile app, you can view, write or assess clinical documents from your laptop, smartphone, or tablet, helping busy practitioners stay on top of their work.

Compliance: Carepatron takes patient privacy very seriously. They meet or exceed HIPAA, HITRUST, and GDPR standards, guaranteeing that your clinical documentation processes are completed safely. Once your notes have been written, bank-level encryption is deployed to ensure that all of your data is safe. Additionally, access to the physical PWS servers is protected 24/7 by professional security guards and other protective features. 

Patient portal: Improving the transparency of the healthcare process and granting patients access to their medical records has become a high priority in recent years. Accommodating this, Carepatron is integrated with a sophisticated patient portal that allows clients to have 24/7 access to their own records.
Medical Dictation in a EHR system.

The Tools You Need to Manage Clinical Documentation (and Grow) Better

Because you shouldn't have to figure out Clinical Documentation on your own.
Clinical documentation cheat sheet
Clinical documentation cheat sheet
Clinical documentation refers to the creation of medical records that pertain to patient healthcare. These documents may contain information concerning symptoms, diagnosis, assessment, treatment, as well as any testing.
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Clinical documentation software for clinicians and their clients

Carepatron’s clinical documentation software was designed in collaboration with various different healthcare practitioners, ensuring that its features are suitable for a diverse group of professions. Regardless of what field of healthcare you work in, Carepatron is guaranteed to elevate your clinical documentation. 

Writing and accessing patient records is a significant aspect of working as a general practitioner. When a patient requires treatment, the physician needs to have instant access to their records to be sure they are making the most appropriate clinical decisions. Carepatron’s EHR system updates in real-time, allowing physicians to have immediate access to all the information required to treat a patient. 
Often, psychologists and mental health therapists find themselves staying at work overtime trying to catch up on their clinical notes. In this field of work, it is of particular importance that clinical documentation is kept updated and is consistently accurate and thorough. With Carepatron’s templates, mental health therapists can adopt a consistent format and feel confident that their progress notes are accurate and contain all of the necessary information.

When a patient is receiving treatment or going through the healthcare system, there is a high possibility that they will be transferred between practitioners, departments, or facilities. As such, it is of utmost importance that inter-provider communication is effective, and all relevant parties can access the patient’s medical records. Carepatron’s EHR system and documentation storage capabilities ensure that communication is seamless and good continuity of care is maintained. Regardless of the field of healthcare that you work in, the features offered by Carepatron will guarantee your documentation is more consistent, accurate, and thorough.
Clinical documentation software for clinicians and their clients

How does our Clinical documentation System work

Carepatron’s clinical documentation software uses cloud-based technology, meaning that all of its data is securely stored on a  remote server. Using cloud technology means that any changes or modifications to the stored files happen in real-time, facilitating better inter-provider communication. Data stored “on the cloud” is accessible to authorized users at any time, from any device, provided they have an internet connection. 

Once implemented, Carepatron’s system will allow you to streamline the entire clinical documentation process. After seeing a client, you can select a note template that elevates the quality and consistency of your notes, whilst simultaneously encouraging them to be written in a timely manner. Following the production of your documents, they are consequently stored in a system that grants 24/7 accessibility to authorized users. Being able to access clinical records is a necessary aspect of continuity of care, and ensuring that all providers remain informed about the current treatment progress of a patient. 

Additionally, by integrating with a patient portal, Carepatron’s system accounts for the increasing desire of patients to have greater involvement in the management of their own care. The portal displays medical records, and patients can also request that their providers upload current progress notes and other forms of clinical documentation, making the treatment process transparent and allowing patients to stay updated and informed at all times. 

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How does our Clinical documentation System work
Examples of Good Clinical Documentation

Examples of Good Clinical Documentation

Whilst the specific contents of clinical documents will differ depending on the field of healthcare you work in and the type of record you are writing, there are certain universally important aspects included in effective clinical notes. 

Accuracy
: Not only does clinical documentation help ensure a patient is receiving the right treatment, but it can be used to protect you and the practice you work for. Your clinical notes need to be accurate, and any conclusions you draw should be supported by quantifiable evidence. The best way to guarantee that your clinical documentation is accurate is to write your notes immediately following a session with a client.

Concise: Whilst it is important that your documentation is thorough, you also need to remember that quality takes heed over quantity. Vague language and excessively lengthy descriptions are unhelpful and merely make the document more difficult to navigate. Every sentence within your documentation should have a purpose, and clinical notes should never exceed two pages.

Consistent: Clinical documentation is frequently shared between other healthcare providers, insurance workers, and lawyers. By emphasizing the consistency of your notes, you will facilitate easier interpretations of the contents. Using clinical note templates, like SOAP and DAP, is one of the best ways to guarantee the consistency of your notes. 

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Guidelines On Writing Best Practice Clinical Documentation

The specific structure of your clinical documents will depend on what templates you use, and your own formatting preferences. However, there are certain universalities that are required within all forms of clinical documentation to ensure that they can be appropriately used:

Patient information: Clinical documents need to include references to the patient’s name, address, contact numbers, and other relevant information. If a document doesn’t include the right patient details, it cannot be used in many contexts. 

Signed and dated: As the healthcare practitioner, you are responsible for the document and consequently need to sign and date it. 

Legibility: Given how frequently they are shared between other providers and third parties, it is critical that your clinical documents are legible. The best way to guarantee legibility is by using Carepatron’s electronic note system, which has the additional advantage of minimizing grammar and spelling mistakes and improving consistency.

Subjective and objective: Whilst objectivity is important, sometimes it is necessary to include subjective information regarding the patient’s current health condition. Any conclusion you draw needs to be supported by some sort of evidence. 

Medical history: Treatment decisions are informed by the patient’s previous involvement in the healthcare industry and as such, their clinical documentation needs to include relevant medical history. This could be past immunizations, operations, allergies, or medications, all of which contribute to the ability to make informed clinical decisions.

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Guidelines On Writing Best Practice Clinical Documentation

Trusted by healthcare professionals

10,000+ healthcare businesses are currently successfully using Carepatron’s practice management software. The benefits reported by these practices are extensive, but don’t just take our word for it:

Nurse Practitioner
“We have experienced significant clinical documentation improvement since migrating. Carepatron provides our private practice with a Cloud-based EHR system to store all medical histories, intake forms, clinical assessment, and treatment plans. It is highly secure, HIPAA complaint encrypting all information within the application. The phone app loads fast and are easy to navigate, so our healthcare team can load clinical notes and update health records as they go rather than scheduling admin days to catch up. I find it easy to learn, simple to use, and quick to navigate across. We use google drive and one drive integrations to quickly transfer our healthcare documents. Our clinicians love how easy it is to switch from scheduling a follow-up appointment to capturing an intake form or medical history. The customizable templates and speech-to-text tools are also incredible.”
Nia D.
Nurse Practitioner
Healthcare Practice Owner
“Better than the best clinical document tool! Its been a real 'wow' experience for our healthcare practice. It has saved our healthcare team time and provides a simple way of uploading medical documentation and updating client health records. We have the confidence now to grow, moving to a paperless intake process and remote healthcare services without bringing in more admin staff to manage this additional work. This healthcare software is easy to use with simple navigation and a beautiful layout. There are no overly complicated command keys, and everything you need to run your healthcare practice is readily available. It has an excellent search capability to quickly find and access the clinical information you need when you require it.”
Min W.
Healthcare Practice Owner
General Practitioner
“One-of-a-kind healthcare documentation software. Carepatron is brilliant online healthcare and patient record system. There are loads of features and pros of the tool. System design and the user interface are excellent. Speech to text reduces the need to transcribe information. The digital consent and enrolment are helpful. The patient portal makes it very easy to share documents and notes with clients or other healthcare professionals. We also use the invoicing and payment capability, which is pretty impressive. HIPAA compliance helps us to stay safe and compliant. Whether it's a small healthcare business or mid-size medical practice. Carepatron is one of the best healthcare solutions out there!”
Smit S.
General Practitioner
Therapist
“Simple to use document management system. It has been great for our healthcare organization. We find it easy and fast to upload a client's medical documents, intake forms, or handwritten notes. The mobile app helps our team to work virtually or on the go. Accessing the information they require when they need it and updating our client records as they do it. We also use the progress note and SOAP note templates a lot which has been a real help.”
Danny J.
Therapist

Clinical Documentation Blogs

Moving to a secure Clinical Documentation program is a big step, but we are confident it represents a significant step forward. We recommend absorbing the following articles to consolidate further your understanding of how Clinical Documentation works and the steps you need to take to implement it.