Medical documentation software characteristics vary between different types of such tools. However, specific requirements must be met by all these tools. Such systems help medical professionals to ensure efficient healthcare delivered to patients.
Some of the critical functions shared by such medical documentation software include:
- The identification of patients and maintenance of accurate and in-depth patient records
- Filing patient demographic details
- Managing the list of health issues/problems
- Storing medication lists and patient history details
- Maintenance of clinical notes
- Recording external clinical documents
- Managing healthcare plans, different protocols, and guidelines
- The generation of instructions specific to each patient
Medical documentation software must accurately record and maintain electronic healthcare records for every patient. These records are then accessed by healthcare professionals whenever needed to perform diagnostics, and interventions, prescribe medications, and so on. Then, the list of health problems is also recorded for each patent, and the list with the types of medication each patient takes.
Patient history is also significant. Here it is included the health record you can find in EHR software and medical records that can be found in EMR (electronic medical records) because there is a significant difference between the two types of systems. Maintaining clinical notes allows healthcare experts to authenticate and transcribe other documentation for clinical notes. The clinical document capturing also allows the inclusion of any clinical documents from previous physicians/interventions or other external health records.
Some other key features typically available in clinical documentation software include:
- The ordering of diagnostic tests- allows healthcare experts to send orders for different diagnostic tests as requested by physicians
- Management of the results- here, all test results are presented to the healthcare experts so that they can review them and make well-informed decisions regarding the continuity of the treatment.
- Managing consent- all patient decisions are maintained through the different authorizations as needed.
- The support for drug interaction identification- whenever health experts order medications, they are issued a warning about the possible drug interactions