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EHR – Practice Management System Features – Notes
This is the third article in my series on Cloud Based EHR / Practice Management Systems. In this article we begin to explore the different features a practice can look for and evaluate. For a more detailed discussion, as well as a five-stop process for selecting an EHR, check out the Guide to Choosing an EHR.
Proress Notes are an integral part of the work of mental health and wellness professionals. Keeping good clinical notes allows a provider to recall information more readily, focus on targeted goals, and track progress. They also allow the provider to document that they are fulfilling insurance company requirements like acceptable standards of care and medical necessity. Often, other notes are kept as well. These may include psychotherapy/process notes, contact notes, appointment cancellation notes, termination notes, assessments and more.
Taking and keeping up with these notes on paper can be a time-intensive task. Ask just about anyone in the field and, next to dealing with insurance claims, they will tell you that paperwork is the top item they wished they could spent less time on. EHRs can often make this process more efficient.
There are many features to consider when evaluating an electronic note taking solution. These include not only the structure/format of the notes, but also insurance and HIPAA requirements. For example, to satisfy HIPAA, you need to be able to sign and lock notes to prevent un-authorized, un-tracked modifications. In addition to Progress Notes, many will find integrated Treatment Plans essential to their work.
What features are most important to you in a clinical progress note application?
Get the Complete Guide
Get fully informed and understand all of the implications of your EHR selection in the Guide to Choosing an EHR. In this book, Rob goes into detail and provides a step by step process for selecting the best fit EHR for your practice.
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Health Information Exchanges (HIE) are an initiative related to the Affordable Care Act and the HITECH Act. Their purpose is to ease the communication between the EHR/systems of various providers of health care, because the EHRs themselves are behind in doing so (i.e. interoperability).
About the Author
Rob has been covering technology and business news for mental health professionals since 2011. His extensive experience in IT, business, and private practice allow him to synthesize information in a friendly, digestible manner. He also enjoys time with his family, ultimate frisbee, and board gaming.