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Clinical Documentation

Clinical Documentation

 
 

MedcomSoft has introduced a new generation of Electronic Medical Records (EMR), powered by Medcin, the most comprehensive point-of-care medical terminology available in the world today. This provides MedcomSoft Record with a foundation consisting of more than 250,000 clinical data concepts compiled over 25 years in collaboration with physicians from Cornell, Harvard, Johns Hopkins and other leading healthcare institutions.

Clinical DocumentationThese clinical data concepts have more than 72 million SOAP links between them, enabling MedcomSoft Record to provide an unparalleled level of integrated intelligence and clinical decision support that cannot be matched by other EMR solutions. MedcomSoft’s unique cross-mapping between the MEDCIN terminology, drug brand names and diagnostic laboratory results provides unprecedented homogeneous patient charts. Automatic linking to other standard terminologies such as CPT, ICD-9-CM, LOINC and SNOMED provides a flexible platform for data exchange and compatibility with other systems and standards.

Features & Functionalities

  • Supports all rapid documentation methods (Click, Type, Write, Dictate, Import or Transcribe)
  • Document directly from the Medcin vocabulary, protocols, clinical templates, free text typing, voice recognition, pre-filled protocols, previous encounters, flow sheets and patient submitted information
  • Real time, pen-based capture of examination data, diagnosis, orders and plans
  • Fully searchable clinical vocabulary by data element, by string, by synonym, by clinical symptom, by disease and by abbreviation
  • Numerically codifies all clinical data elements including laboratory results and prescribed drugs
  • One click review of a condition progress in a flow sheet format
  • One click review of entire patient chart summary
  • Dynamic decision support tools
  • Dynamic health maintenance alerts
  • Extensive library of pre-designed templates
  • Easily customizable templates and care protocols
  • Includes extensive specialty specific library of pre-built intelligent point-and-click templates
  • Ability to import and export clinical form templates
  • Automatic narrative creation integrated with correspondence and mail-merge
  • Fully automated E&M coding and superbill
  • Engineered for use in all specialties
  • Includes powerful interfaces to ancillary systems (medical laboratories, pharmacies, Diagnostic testing) and devices
  • Automatic population of community clinical data repositories
 

EMR & PM Components

  Scheduling
  Patient Registration
  Clinical Documentation
  Order Entry
  Document Management
  Decision Support
  Referrals & Authorizations
  Charge Capture
  Claim Submission
  Health Maintenance
  Workflow Tools
  Data Mining
  Interoperability
  Patient Education
  Compliance & Security
 

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