Clinical Documentation & Compliance Management

Our comprehensive clinical documentation and compliance management features help provide quality patient care at the lowest possible cost. This ensures full compliance with all federal and state regulations. Our flexibility, ease-of-use, and consolidated reporting tools reduce the cost of initial training, ongoing document preparation, and periodic management review.

Electronic Clinical Documentation reduce administrative time needed to prepare documents

  • Exceptional flexibility plus highly automated tools with access to documentation libraries saves time while promoting compliance.
  • Enter Plans of Care, Daily Notes, Progress Reports, Re-certifications, and Discharges Summaries in 15 minutes or less daily.
  • Focus therapists' time on providing high quality therapy services.

Patient Alerts identify quality control or clinical compliance errors automatically

  • Alerts appear automatically when logging on or in Patient Central and Scheduling.
  • Alerts are cleared when corrected or with the passage of time automatically.
  • Identify quality control, compliance, or operational errors before providing treatments.
  • Quality Control and compliance alerts include Treatment Required Every 10th Visit, Re-Certification Note Due In 3 Days, Medical or Treatment Diagnosis Missing; and Plans of Care, Daily Note, Progress Report, or Discharge Summary Missing.
  • Operational alerts include Patient in Assessment Period, Evaluation Not Entered, Patient Not Discharged, and Medicare Part A Benefits Run Out In 7 Days.

Activity Monitor tests all charges for quality control and compliance automatically

  • Compliance tests all charges to ensure full reimbursement for therapy resources used.
  • All charges are tested for CMS minute parameter, CCI Edit, composite treatment, once-per-day, and other errors.
  • Identify charges that might have been missed by misapplying the 8 minute rule.
  • Eliminate denials from charges with insufficient minutes or those requiring modifiers.
  • "Live" reports save time because therapists can make corrections easily right on the report.
  • Streamline management by monitoring quality control and compliance with ease.
  • Modifiers are assigned to all treatments for the entire week with the click of a button.

Outcomes Management tools measure and document patient improvements objectively

  • Create your own custom outcome measurement scales or use broadly accepted standards that can be built right in.
  • Create outcome scales for ADL's, mobility, cognition, and more.
  • Prepare Outcome studies for a patient, a facility, or for your entire company.

Documentation Entry provides the optimum balance of exceptional flexibility plus highly automated tools

  • Produce clinical documents easily providing more time for patient care.
  • Document each patient's progress using a flexible format of library entries and free form text entries.
  • Includes easy-to-use tools to plan and prioritize treatments, measure their effectiveness, and communicate results to other providers.

Documentation Libraries improve document quality by empowering managers to control the content of documents prepared

  • Lists of CPT code activities, goals categories, treatment goals, functional assessments, and measurable data guide your therapists in quality document preparation.
  • Use our standard library entries or create you own custom library.
  • Use our library entries "as is," select and edit entries as needed, or create a completely new entry in any document "on the fly."

Our unique "Document Copy" function reduces document preparation time and improves document quality

  • Copy a patient's history, plan of care, goals, daily notes, and more from one document to the next with the click of a button.
  • Changes can be made "on the fly" to ensures that all of the documents for each patient are consistent and will stand up to review in all cases.

Clinical Documentation Reports save time and improve document quality because managers can review documents easily

  • Review all document types for any period by facility, payer, patient, or discipline.
  • An array of clinical management tools improves document quality before review.

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