Clinical Documentation

Electronic Medical Records

Clinicient EMR Clinical Documentation software was specifically developed for Physical Therapy, Occupational Therapy, Speech Therapy and other Outpatient Rehabilitation practices. Designed to replicate the paper forms you’re familiar with as a therapist, Clinicient Clinical Documentation is paperless, so you can spend more time focusing on patient care and outcomes.

Clinicient helps therapists create physical therapy documentation that is simple to use, easy to customize, fast and compliant. And with the Clinicient web-based software system it’s all fully integrated so you can share PT documentation, notes and records with your staff as needed – and access files even when you’re away from the office. Learn more about the many features of Clinicient’s Electronic Medical Records Clinical Documentation.

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