Automated records systems support clinical documentation management

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Automated records systems support clinical documentation management

Clinical documentation that is prepared accurately, uploaded timely and downloaded cleanly into an electronic medical record (EMR) can enhance patient care, improve workflow and support improved reimbursement. But once inside the EMR, documentation isn’t always easy to access or easy to use.

That’s where an electronic documentation management system can be beneficial for hospitals and other facilities, ensuring that clinical data can be moved or accessed in an accurate, timely and secure fashion.

So what are some of the features you should be looking for in a good documentation management system?

First, you want one that offers remote access. This makes it easy for providers to see dictated and transcribed documents via any secure web server. As cases are transcribed, they should be prepared and placed onto the web server.

Second, you want a system that allows authorized users to access records on demand—one that allows them to access new and past dictation at their convenience. This records-on-demand feature should allow users to:

  • Review dictated records
  • Print reports
  • Monitor turnaround time
  • Verify invoices
  • Upload to hospital EMRs
  • Use audit trails to review file access history

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