Learn More About Clinical Documentation Software
What is Clinical Documentation Software?
Clinical documentation software refers to solutions healthcare providers and their staff use to create digital records detailing medical treatments, tests, or trials. This documentation supplements longitudinal patient records typically stored in EHR/EMR systems, which centralize all healthcare information for a patient. Clinical documentation software captures any patient encounter at the point of care and can be accompanied by a variety of imaging and testing files to provide additional context.
Most clinical documentation software can electronically record information in real time using dictation features, in addition to being able to integrate with document scanning tools to upload paper records. From pre-appointment to post-appointment, this software manages intake forms and questionnaires, patient identification materials, insurance documents, claims and billing, discharge information, and educational guidance. Clinicians rely on it to create workflows that simplify point of care documentation. Its compliance features ensure that all documentation is error-free.
What are the Common Features of Clinical Documentation Software?
The following are some core features within clinical documentation software that help healthcare teams maintain compliant medical records and improve document management workflows:
Templates: Templates streamline the documentation process for healthcare professionals so it’s easier to complete SOAP notes, prescription orders, or treatment plans. Providers can fill out the necessary forms during patient care thanks to the software’s point-and-click functionality. That means clinical workflows remain unobstructed when labs, images, or medication need to be ordered.
Image uploading: Through connection to other systems and hardware, clinical documentation software supports image uploading from fax machines, scanners, emails, and other electronic sources. This helps office staff capture patient intake and insurance information, and lets multiple providers collaborate on patient care more effectively by ensuring they all have access to comprehensive documentation.
Clinical workflows: Clinical documentation software supports automated workflows for tasks related to billing, care collaboration, and compliance. This reduces time spent on ordering labs, tests, and prescriptions, and promotes accurate code capture. Most products can alert users when documentation is incomplete or inaccurate, which reduces rejected healthcare claims and guarantees coding staff are compliant with current standards. Access to information can also be restricted depending on the user’s role.
Note dictation: Voice-to-text functionality allows clinicians to dictate notes in real time or convert recorded audio into notes. This saves time during routine medical exams and promote more meaningful interactions with patients, while still maintaining thorough medical records.
Document management: On the administrative side of healthcare, clinical documentation software helps office staff maintain organized records for simple retrieval and auditing purposes. Coding and labeling of medical information properly supports billing and claims processes, and makes it easier to locate patient information. Offices can also take advantage of this tool to digitize their records and move away from paper-based document filing systems.
What are the Benefits of Clinical Documentation Software?
Reduced administrative workload: Clinical documentation software dramatically lowers the amount of time spent on documentation so clinicians can spend more time providing quality care to patients. Templates, coding and filing workflows, and multi-system interoperability help healthcare staff maintain current patient records, maximize reimbursement from claims, and collaborate on care more efficiently.
Automation for decision workflows: Proper clinical documentation supports evidence-based processes, such as healthcare claims and patient referrals. This software can automate the decision-making process by screening for particular medical codes or specific patient documentation.
Audit trails: By digitizing paper records and promoting thorough documentation, clinical documentation software helps healthcare organizations stay compliant with important regulatory standards such as HIPAA and ICD-10. Billing departments in particular depend on accurate documentation to make decisions. This software creates a holistic picture of patient journeys and expedites review processes for approving prescriptions, imaging and tests, and any revisions to existing documentation.
Improved patient outcomes: At both an individual patient level and a global level, clinical documentation software supplements patient records and provides the basis for public health registries.
Who Uses Clinical Documentation Software?
Doctors and clinicians: Doctors and clinicians use clinical documentation software to capture patient information during medical appointments, which then populates their patient record. This documentation helps generate after-care summaries, referrals to other providers, and orders for prescriptions, labs, and imaging.
Billing and coding staff: Revenue cycle management is an important process in healthcare systems. Billing and coding staff rely on accurate clinical documentation captured by this software to submit and evaluate claims.
Clinical documentation specialists: Increasingly, healthcare organizations are employing dedicated clinical documentation improvement (CDI) specialists to oversee documentation processes. These specialists use clinical documentation software to verify accuracy and flag any errors that affect compliance, reimbursement metrics, or patient safety.
What are the Alternatives to Clinical Documentation Software?
Alternatives to clinical documentation software can replace this type of software, either partially or completely:
Medical transcription software: Depending on the needs of a healthcare organization, medical transcription software may be more appropriate if a provider is simply looking to reduce time taking notes during patient appointments. Medical transcription software already supplements clinical documentation workflows, making it easy to convert audio into notes that populate a patient’s record.
Software Related to Clinical Documentation Software
Related solutions that can be used together with clinical documentation software include:
EHR software: Clinical documentation software captures patient information and stores it in the electronic health record. This can include medical history, test results, diagnoses, and treatment plans. Clinicians can quickly update a patient’s record with notes captured at the point of care. A good clinical documentation software drastically reduces time spent on paperwork and ensures that patient data is captured in a timely, accurate manner, and then populated into the EHR.
Medical practice management software: Clinical documentation software can interface with medical practice management software to provide additional context to patient information, organizational documents, and billing.
Healthcare claims management software: Healthcare claims management software serves a similar function as clinical documentation software: digitizing documentation and speeding up workflows. This software reduces errors in billing and coding, and increases revenue captured from claims.
Challenges with Clinical Documentation Software
Clinical documentation solutions can come with their own set of challenges.
Evidence-based automation: While clinical documentation software provides useful automation, evidence-based workflows may suffer consequences as a result. Patient care is full of nuance, and relying on software to approve or deny claims or collaborative care can result in worse healthcare outcomes. CDI specialists can help contextualize patient information and catch any errors in documentation that negatively contribute to this process.
Adoption of the software: For practices that have been accustomed to a paper-based document management system, clinical documentation solutions may come with a strong learning curve. Staff need to decide on an information management process and then tailor their use of the software accordingly. Patient information management may suffer if clinicians aren’t utilizing the software during appointments. Similarly, billing and coding staff may not immediately benefit from the automation this software provides if they’re not trained properly, and claims reimbursement may still be affected.
How to Buy Clinical Documentation Software
Requirements Gathering (RFI/RFP) for Clinical Documentation Software
Whether an organization is just starting to explore clinical documentation software or is looking for a more appropriate solution for their needs, G2.com can help inform buyers of the market and assist them in selecting the best software product for their business.
Buyers should consider what is and isn’t working with their current system and use that information as a starting point. Some questions they might ask are:
- What are the pain points in the existing document management system?
- Do we need a cloud-based solution?
- Is voice dictation a required feature?
- What is the primary benefit we seek from clinical documentation software?
Understanding the weaknesses in their current system eliminates any potential new products that won’t alleviate those concerns. Beyond that, required integration with specific EHR systems may disqualify some products. Buyers should also understand the level of support each vendor offers when migrating data from existing systems into a new product.
Compare Clinical Documentation Software Products
Create a long list
Creating a preliminary list of products that fit the buyer’s general needs is the first step to finding the perfect software solution. The next is narrowing down the list by selecting specific features that are must-haves for the buyer. Clinicians may have a different list of potential products than the billing and coding staff because of differing needs for integrations or specific features. G2.com provides information about the best clinical documentation software, allowing buyers to filter options and user reviews to help refine the product list to a more relevant selection.
Create a short list
Making a short list of software products is an important step in the buying process. While it may be daunting to filter through various products, users can get help by utilizing G2’s compare feature. This feature displays prospective products side by side so the buyer can easily determine which software ticks the right boxes.
Conduct demos
Once the buyer has refined their product list, they should conduct a demo to experience a product and its features in action. The buyer has to prepare before the demo to make sure they’re getting the most out of it.
Some questions to keep in mind may include:
- Does the product trigger alerts for incomplete or inaccurate documentation?
- Can users collaborate on documents?
- Does the software support document archiving?
- What types of workflows can we establish for review and approval processes?
Additionally, buyers should inquire about cost, integrations, vendor support, and any other concerns they have about the product. Adequate preparation makes it easier for buyers to compare products after completing the demos.
Selection of Clinical Documentation Software
Choose a selection team
Since clinical documentation software is used for different purposes with regards to patient information management, the selection team should represent the interests of the clinical, administrative, and financial departments. For instance, clinicians have a different threshold than billing staff for what constitutes a good clinical documentation product.
Negotiation
Once the selection team has narrowed down their software picks, it’s time to discuss customization options, pricing, and the type of support they need from the vendor. It’s always important to address pricing options, even when they are listed on a vendor’s website. Many software vendors provide discounts and custom pricing options based on what the buyer is looking to purchase.
Final decision
Right before the final purchase, the team should enquire about a trial run and determine the next steps if the product doesn’t ultimately fit their needs. These steps give buyers more security and confidence when deciding. Buyers also have to understand the level of post-purchase support their selected vendor will provide and whether implementation or training support will resolve any issues.
