Clinical Documentation
Clinical documentation systems can enhance patient care by allowing clinicians to quickly document care electronically at the bedside and then create patient specific reports, show trends and provide alerts. The “e-chart” is available to all EMR users instantly. The use of electronic clinical documentation empowers your staff with the information they need to make patient care decisions at the point of care and to follow best practices.
Healthcare Informatics Associates (HIA), an InfoLogix company, has the experience and the expertise to fully assess your current documentation forms and assist you in developing the optimal future-state incorporating best practices. We can then assist you in implementing a new electronic clinical documentation system and training your staff to use the system.
Some of the key elements of clinical documentation HIA can assist you with are:
- Advanced planning and budgeting to ensure success
- Multi-disciplinary clinician charting and documentation (from nursing to ancillary to physicians)
- Care planning and patient documentation
- Advanced flowsheet documentation
- Electronic medication administration documentation
- Integration of point of care devices in the documentation workflows
In addition, HIA consultants can help you take the next step in using clinical data to improve quality by assisting in data mining and report creation so that you can better track and predict patient care scenarios.