Client demographics are maintained and include ethnicity, multiple contacts, employment history, authorizations and billing information. This information is maintained historically and available by simple search and retrieve.
Information gathered in one area of the software is populated in other areas as needed to eliminate double entry and maintain consistency. Drop selection boxes are used through-out for answers reducing key strokes and verifying that valid data is being input into the database.
Attach a photo ID to the client record as well as scan in paper documents for electronic storage by client..
The Assessment software allows for the complete control over the organization and information deemed necessary for a complete patient assessment. By allowing for electronic record keeping, staff are able to view information that has been asked by other staff members and eliminate some of the duplicate record keeping and information gathering.
Clinical Assessments include but are not limited to:
Both Admit and Discharge Diagnosis assignment of DSM codes for AXIS I through V
The treatment planning software eases the burden of producing paper documentation of treatment plans. Clinicians have the ability to create their own problem statements and interventions and a plan library that includes interventions for most common problem statements is also available and maintained by the clinical supervisor. Multiple review forms can be generated through the software. The treatment plan software also is coordinated with progress notes software to include problems identified in the treatment plan as note captions in the patient progress note records. Each treatment plan is in the ASAM six dimension format including Problems, Goals and Strategies.
The Progress Notes module allows for the easy and simple documentation of patient interactions, whether it be nursing records or individual or group counseling sessions. Clinical editors have the ability to designate note captions as well as create note templates that can be made available for easy record keeping.
Group Progress Notes
The clinician can access one screen to chart on a group of patients. The notes can be tailored and individualized appropriately for each patient with a sidebar capability and when the clinician signs the note, the records are added to each patient's individual patient record eliminating the need to open each individual record and chart one at a time.
Discharge Summary And Aftercare Planning
The Discharge Summary uses the same clinical supervisor editing functions as the admissions assessment to create a discharge summary individualized by the treatment center. Templates can be made for ease of record keeping by eliminating the entry of common statements.
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