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 eMAR system is fully integrated and allows information collected at the point of care to be combined with specific details from resident admission information, physician orders, care plans, nurse notes, specific clinical assessments, and other clinical documentation in the medical record.
Structured clinical documentation (SCD) is designed to overcome this problem with clinicians selecting terms from a fixed list or vocabulary.
Most of these packages are equipped to handle the core needs of a smaller facility: resident assessments, reimbursement, clinical documentation, and basic management reporting.
Contract award notice: Service of distribution and transport of samples, Sanitary clothes, Administrative and clinical documentation, Storable material and pharmaceutical products, As well as parcel service, Respectful with the environment (spain-llerena: Parcel transport services)
Physicians now must make certain that the ICD-10 codes submitted on claims reflect the clinical documentation and are accurate.
(www.chartwisemed.com), the award-winning industry leader in Computer-Assisted Clinical Documentation Improvement (CACDI) software, is pleased to announce the appointment of Tom Emberson to the position of vice president of sales and marketing.
The combined companies make up the one of the largest global clinical documentation service providers and share an ultimate goal of driving positive results and success for healthcare clients worldwide.
In addition, Anthelio will leverage M*Modal's Fluency for Transcription speech recognition and workflow platform as well as M*Modal's network of global transcriptionists and editors to support Anthelio in meeting customer demand for high-quality clinical documentation. Finally, Anthelio will offer M*Modal's front-end speech recognition solution Fluency Direct to its customer base, enabling physicians to verbally capture patient records directly in electronic health record system templates.
24 July 2012 - US clinical documentation solutions firm MModal Inc (NASDAQ:MODL) today said that the waiting period under the Hart-Scott-Rodino Antitrust Improvements Act in relation to its planned takeover by One Equity Partners (OEP) had expired.
Provider of clinical documentation services M*Modal (NASDAQ:MODL) on Wednesday announced that Duke University Health System (DUHS) has selected it's cloud-based Speech Understanding technology.
Much of this has been driven by competition among vendors to provide improved technology support for required clinical documentation of resident care.
* A clinical documentation program for the entire medical center set up in conjunction with Milliman & Robertson (M&R) (10)
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