How Our Clinical Documentation System Works

Clinical documentation records all interactions between patients and their healthcare professionals. They help improve continuity of care, guarantee reimbursement, and serve as evidence in any malpractice suits.

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Benefits of clinical documentation

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What is clinical documentation?

What is clinical documentation?

Clinical documentation records all points of interactions between patients, and is an integral aspect of working as a healthcare professional. Clinical documents are applied in various situations and are a useful reference for healthcare providers. They help improve continuity of care, guarantee good reimbursement, and serve as evidence in any malpractice suits. As such, maintaining accurate and consistent clinical documentation is an extremely important part of being a healthcare provider. In recent years, the number of physicians writing their records online has increased significantly and there has been a widespread development of clinical documentation systems for healthcare businesses. The benefits of these systems are reflected in the massive growth in the industry, which is expected to reach USD $ 1,336.97 million by 2025.

What is the purpose of clinical documentation?

Clinical documentation serves a wide array of purposes. Firstly, and most importantly, it is used to elevate patient care. Good clinical documentation is positively correlated with good clinical outcomes, which should always be the main objective of delivering healthcare services. By recording accurate details pertaining to a patient’s treatment, continuity of care is much more likely to be effective. Communication between healthcare providers involved in the care of the same patient is facilitated by precise clinical documents, and physicians can feel confident that they are equipped with all the information required to suitably treat a patient. 

Secondly, clinical documentation is important for reimbursement purposes. Accurate clinical notes will indicate to insurance companies the exact services that were performed, and allow you to get reimbursed faster. The medical billing and reimbursement process is becoming increasingly complicated, so ensuring that your documentation is timely and accurate will help reduce the number of rejections and denials your practice receives. 

Lastly, some forms of clinical documentation are legal records and can be used as evidence in malpractice suits. Maintaining high-quality clinical documentation will ultimately protect you in these unfortunate situations by providing a transparent record of the entire treatment process.

What is the purpose of clinical documentation?
Improving clinical documentation with Carepatron

Improving clinical documentation with Carepatron

Unfortunately, some busy physicians end up putting clinical documentation on the back-burner so they can complete other tasks and attend appointments with patients. Whilst this is understandable given how time-consuming maintaining good clinical documentation is, letting these records pile up increases the chance of poor clinical outcomes for patients, lengthy reimbursement processes, and lack of protection against lawsuits. Fortunately, the development of clinical documentation systems has provided practices with a sophisticated tool that can streamline their documentation process and save physicians and administrative staff countless hours. The vast range of these systems can make selecting one that is right for your business difficult, which is where we can help. 

Carepatron offers a HIPAA-compliant clinical documentation system that is guaranteed to help your healthcare business meet its goals. The system was designed in collaboration with various healthcare professionals, so you can feel comfortable that the tools it offers will directly benefit your practice. Using Carepatron as the software for your healthcare business will allow you to boost productivity whilst simultaneously creating accurate, timely, and consistent clinical documentation.

Understanding the function and mechanism of Carepatron's clinical documentation system

So how exactly do clinical documentation systems work? Carepatron’s software uses cloud-based technology, meaning that all information and data is stored by a remote server, where it is said to be “on the cloud”. This allows all clinical documentation to be accessed by authorized users at any time from any device, provided they have an internet connection. Further, one of the biggest concerns of implementing new electronic systems is related to patient privacy. Clinical documentation typically contains highly confidential information, relating to the patient’s personal details, and in-depth commentary on their medical history. Carepatron takes privacy very seriously and is a HIPAA-compliant platform. The information uploaded onto the system undergoes bank-level encryption, reducing the risk of any unauthorized access or data leakages. 

From the perspective of healthcare physicians, Carepatron’s clinical documentation system will allow you to streamline what is otherwise a time-consuming process. The system offers a variety of note templates, including SOAP and DAP, that will elevate the consistency of your notes and ensure they are written in a timely manner. Once they have been created, they can be uploaded into the system, where they are accessible 24/7. Accessibility is one of the most critical aspects of clinical documentation storage, as these records frequently need to be viewed by a range of providers to guarantee good continuity of care. Further, the EHR system that is integrated into Carepatron’s platform is updated in real-time, ensuring that providers can access any important changes to a patient’s health condition or status. Instant access to clinical notes is also facilitated by the mobile app offered by Carepatron. With these features, healthcare providers and patients can have immediate access to pertinent records, allowing them to stay informed about the current treatment progress of a patient. 

Carepatron also caters to the growing desire of patients to have greater involvement in the management of their own care. The Carepatron system is integrated with a patient portal that grants clients continuous access to their own medical records. 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. 

Additionally, the clinical documentation features offered by Carepatron are integrated with various other tools all designed to assist with the organizational tasks of a healthcare practice. These include appointment scheduling software, medical billing, and coding features, secure video conferencing, and the option of online payments. The culmination of all of these resources means that your practice can efficiently organize all of its administrative tasks from a single, secure platform, saving you significant amounts of time and energy that can instead be spent seeing and treating more patients!

Final thoughts

Carepatron offers the perfect solution for any healthcare practice looking to improve their clinical documentation. Not only does it streamline this process for physicians, but its interoperability and integration with various features allow you to organize numerous tasks on a single platform. Depending on the specific requirements of your practice, Carepatorn offers two pricing plans. The free version is ideal for individuals and small practices who are just starting out. It comes with 300MB storage capabilities and unlimited client and staff, appointments, and 1-on-1 video conferencing. Alternatively, the other plan is $29 USD pp/month and is designed for larger practices or those looking to grow their business. It offers unlimited storage capabilities, all of Carepatron’s features, unlimited group conferencing calls, and has a guaranteed 99.99% uptime. Upgrading to the paid plan can be done at any time and contains no hidden costs, allowing you to have flexibility in the decisions you make. 

Regardless of what plan best suits your business needs, Carepatron has something to offer for everyone. Clinical documentation systems are undoubtedly the way of the future and by streamlining these processes, you will inevitably save significant amounts of time, resources, and energy!

Further Reading:

Understanding the function and mechanism of Carepatron's clinical documentation system

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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. While there is no straightforward or universal standard when it comes to clinical documents, they are used by over 90% of health practitioners in the US and provide relevant insight concerning the patient health experience.
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How to manage clinical documentation securely in a new medical practice?
Clinical documentation is an essential component of healthcare practices as it ensures that all relevant details pertaining to a patient’s health are recorded. Regardless of your healthcare discipline and the structure of your practice, clinical documentation is absolutely integral to the operations of your business. Roughly around 65% of patient medical health records contain misinformation and false tests, largely due to ambiguous abbreviations, sloppy handwriting, mixed patient data, and incorrect terminology, which is all very concerning!
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Transferring documentation onto the cloud - important things to know
As new technology developments are increasingly impacting the healthcare industry, we are seeing more and more practices using cloud-based systems. These ‘cloud’ storage systems refer to the use of information, applications, and resources via the internet. Cloud-based systems are utilized by all types of healthcare professionals, and they have been shown to significantly increase productivity and efficiency, as well as have the additional advantages of reducing costs and improving clinical outcomes.