The Clinical Documentation module offers broad flexibility to create, edit, electronically sign, and secure documents, while ensuring compliance with organizational policies. This module enables a fully automated Electronic Medical Record (EMR) in a virtually paperless environment.

• Create document templates using Microsoft Word® or structured data entry forms (Sybase PowerBuilder®).
• Utilize standard data entry fields, such as check boxes and drop-down lists, to ensure consistent information across the organization.
• Auto-populate data gathered in other modules, such as patient name, ID number, diagnosis, and clinician names.
• Sign documents electronically, using password re-authentication.
• Grant or restrict access to patient documents, based on staff security permissions.
• Review personalized To-Do lists and receive reminders of documents to complete, sign, or co-sign.
• Automatically create document for clinicians to complete, based on associations with procedures (service codes).
• Assign proxies, who are given the rights to transcribe documents on behalf of clinical staff, prior to a clinician's review and signature.
• Employ the Quality Assurance process to send documents to QA staff for review, based on system options.
• Enforce billing rules, such as preventing bills from being produced unless the required documentation is complete and electronically signed.
• Incorporate the rich treatment planning module with all other clinical documents.