clinical documentation

clinical documentation

The capturing and recording of clinical information, often in real time whilst the patient is present—e.g., during consultation, assessment, imaging, and treatment.
References in periodicals archive ?
The planned integration will enable Allscripts EHR users to access CypherLink, a clinical documentation guidance tool, from within their clinical workflow.
More specifically, the time is now to consider the real goal of ICD-10: actually improving the level of clinical documentation.
com), the industry leader in Computer-Assisted Clinical Documentation Improvement (CACDI) software showcased its new ChartWise 2.
M*Modal, a leading provider of clinical documentation and Speech Understanding solutions, today announced that it has successfully completed its financial restructuring, reducing its debt by 55%, and has emerged from Chapter 11 Bankruptcy.
EduCode Doc Briefs is available on its own or with EduCode Clinical Documentation Improvement, another offering in Elsevier's Clinical Documentation solution.
NASDAQ: NUAN) today announced Clintegrity 360[TM], an integrated computer-assisted system for clinical documentation improvement (CDI) and coding that helps physicians seamlessly deliver the most clinically-accurate and complete medical records while also supporting coding, compliance and quality teams with the most advanced set of Clinical Language Understanding (CLU) tools.
Russo, a consultant to healthcare organizations, presents principles for creating a clinical documentation improvement (CDI) program that can be used in any healthcare organization.
Whether it's the migration to value-based purchasing and pay for performance, increased scrutiny under the federal recovery audit contractor program or simply achieving internal benchmarks, pressure is mounting on hospitals to improve clinical documentation.
a leading provider of medical transcription services, and a leader in technology-enabled clinical documentation workflow, continues to build partnerships with the nation's top healthcare organizations by developing and implementing solutions that form the backbone of clinical documentation workflow management.
The Dragon NaturallySpeaking SDK Server Edition is designed to be integrated into clinical documentation systems by transcription service organizations, healthcare ISVs, and systems integrators.
A pharmacy system can integrate with clinical documentation and CPOE to achieve value from a quality and service perspective, and support the entire medication use process.
Much of this has been driven by competition among vendors to provide improved technology support for required clinical documentation of resident care.
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