Benefits

Your goal as a physical therapist is to provide the best possible patient care. Electronic medical reports enable you to focus on your PT patients, and Clinicient’s Clinical Documentation practice management system makes it incredibly easy. You can increase efficiency, decrease errors and spend your time where it matters most – benefiting your entire practice.

EMR Clinical Documentation:

• Includes an extensive library of chart templates easily customized to accommodate all types of therapy specialties
• Allows therapists to quickly document with minimal typing
• Provides the flexibility to easily create protocols for any type of patient condition, discipline, workflow or treatment
• Easily monitors patient progress, saving time and improving patient care; assess patients, figure patient plans, and set goals
• Provides the ability to communicate quickly and professionally with physicians
• Maximizes revenue per therapist and assures faster payment
• Ensures compliance, eliminating worries and allowing therapists to focus on treating patients
• Simplifies staff and billing efforts with an intuitive, integrated software system

View our Clinicient Clinical Documentation video demos to learn more about our physical therapy documentation software, the benefits of electronic medical records, and how they can assist you and your Outpatient Rehabilitation business.

Features

Thanks to the Clinicient Clinical Documentation web-based, paperless system, you’ll be better connected to all aspects of your therapy practice – and to your patient. Flexible and configurable, it’s the ideal practice management solution:

Designed by a Therapist for Therapists:

• Large customizable content library for PT, OT, Speech, Pediatrics, Women’s Health and more
• Customizable initial evaluations, daily notes, progress notes, SOAP notes, discharge summaries, tests and measurements, and patient administered outcome scales
• Ability to document therapy notes at the point of care
• Anatomy-specific and condition specific templates with easy to use picklists
• Simple point and click charting using pre-defined custom picklists, with the ability to type a response or easily add free text as needed
• Ability to create and add customized treatment protocols, test and measurement protocols, and plans of care with a single click
• Easy-to-view flow sheets and copy forward from previous visit

Tracks Patient Progress and Communicates Results Professionally:

• Ability to rapidly capture test results and flag important items to track
• Prompts for defining and tracking clinical goals and outcomes
• Customizable progress ratings that support quick assessment summaries of each goal
• Ability to quickly update goals and create progress notes from any visit
• Ability to see report build as treatment is documented
• Free e-faxing of clinical reports at signoff
• Ability to add or remove items from chart templates as needed; non-required items left blank are deleted from reports, eliminating unnecessary clutter
• Customizable form letters, allowing for quickly created correspondence pre-populated with selected information
• Multiple reporting format options; select most suitable reporting format for each referring

Keeps Therapists Compliant:

• Required fields that prevent signoff, helping ensure compliance
• Support for CMS progress tracking requirements: initial value, last measure value and goal completion date
• Ability to drag and drop goal organization and numbering according to CMS guidelines
• Association of clinical procedures with goals to help justify medical necessity
• Built in, regularly updated Correct Coding Initiative (CCI) edits
• Time in/Time out logging for individual procedures as required by Medicare
• Ability to edit time at the charge ticket or individual procedure level; automated synchronization with flowsheets and daily notes
• Medicare Plan of Care and Progress Notes tracking and alerts
• Required fields and automated inclusion of information to minimize audit risk

Maximizes Therapists Revenue:

• Billing integration to ensure compliance
• Rules to notify therapists about payer specific requirements before signoff
• Billed time to patient time comparison to track for underbilling and overbilling
• Automatic prompts for Medicare bonus (PQRS) opportunities
• Automatic procedure code and units calculation based on documentation (therapist time and procedures) according to payer-specific billing rules
• Paperless charge tickets created at sign-off and pushed directly to billing
• Patient visit automatically ready to bill at completion of appointment
• Automatic alerts to catch missing billing information
• Fully loaded, searchable and regularly updated ICD-9 diagnosis code

Increases Therapist Productivity:

• Access from home or anywhere with an Internet connection
• Personalized to-do lists that track unsigned documentation and daily tasks, ensuring payment and compliance
• Ability to attach scanned documents to patient case information at no additional cost
• Ability to track therapist productivity by time, visit, charges and reimbursement

Compliance

Coding and documentation errors can result in fines, penalties, denied claims, exclusion from Medicare and Medicaid programs or even a loss of your practice. Clinicient integrates information and processes, making it easy for therapists to accurately complete all the different types of documentation—the evaluation/plan of care (POC), certification, progress reports and treatment notes for each day of treatment, exception justification—needed to demonstrate medical necessity and enhance the quality of patient care.

• System-driven Compliance
• Long Term and Short Term Goal Tracking with Functional Outcomes
• Automated Charge Capture following Medicare Rounding Rules, based on timed minutes
• Automated Pre-auditing of every visit at Sign-off
• Physician Reporting

 

Compliance Features

• Manual Medical Review Phase Tracker
• Automated and accurate Therapy Cap Tracking and Alerts for $1880 and $3700 thresholds
• Time-based, Long Term and Short Term Goal Tracking with Functional Outcomes
• Fully customizable templates to accomodate Medicare changes and updates, therapists preferences
• Electronic Signatures
• Flow Sheets
• Embedded Plan of Care in Initial Evaluation with physician certification page
• Automatic progress report generator / fax at visit sign-off
• Progress Report tracking and alerts
• Automated charge capture at sign-off – applies CCI edits, calculates units automatically based on therapists time
• Visit Auditing at Sign-off: Alerts to over/under-billing, modifiers, exceptions process
• Automated routing to supervising therapist for review and co-signature
• Task Manager to alert Front Desk for signed ABN from patient
• Automatic backup and data recovery
• Access and usage controls

 

Medicare Compliance Benefits

• Enables therapist to electronically document evaluation/POC, certification, progress reports and treatment notes for each day of treatment in a single, easy to use system
• Provides workflow rules, triggers and notifications to ensure documentation is complete and accurate
• Ensures documentation demonstrates services are reasonable and medically necessary and backs up claims 100%
• Removes unit calculations and coding burdens and prevents coding errors with built-in CCI edits
• Maximizes revenue with automated billing rules to accurately calculate billing units based on therapists minutes
• Ensures bills are accurately coded and  backs up claims 100%
• Presents a professional image for therapists with patients, physicians and payers
• Reduces audit risks with Medicare and Medicaid programs

 

HIPAA Compliance Benefits

• Protects patient security and privacy of protected health records
• 5010 and IDC-9/10 compliant
• Aides in diminishing audit risks and avoiding stiff financial and civil penalties for non-compliance
• Eliminates denied and unprocessed claims for non-compliance

Screenshots

Customizable Chart Templates

See Your Report Build As Your Create It

Communicate Progress Professionally

View Chart Ticket at Sign-off

Demo