What is clinical documentation?
Clinical documentation is any paper or electronic note a clinician makes on a patient’s condition or treatment in their medical record. The production of a digital or analog record of a medical procedure, clinical trial, or test is known as clinical documentation (CD). Accurate medical statistics are based on high-quality clinical documentation.
Clinical records must be precise, updated, and reflect the precise services offered to a patient. Supporting electronic files, such as magnetic resonance imaging (MRI) images, X-rays, electrocardiograms (EKG), and monitoring recordings, are frequently included with paper or digital paperwork.
Clinical documentation providers:
- Suki:
AI-backed and voice-enabled clinical documentation solutions provider. It gives clinicians access to a computer assistant that can listen to patient-doctor interactions, record them, and then aid doctors in taking oral notes using natural language. It employs cloud computing and NLP.
- Simbo.AI:
Simbo.AI serves as a “virtual resident physician” to assist physicians in producing clinical documentation. The Al would do real-time documentation based on Doctor-Patient conversations and commands from the doctor. Physicians become more productive and concentrate on patient care rather than administration tasks. Simbo’s AI-Powered Medical Scribe technology not only streamlines medical note-taking but also summarizes patient-doctor conversations, creating 100% accurate documentation in your EMR without disrupting your current workflow.
- Nuance:
Thirty percent of patients in ambulatory settings see physicians for no more than ten minutes at a time. Clinical documentation that writes itself, a service provided by Nuance, helps physicians make the most of their time by reducing the amount of time spent on it by more than 50%. Clinical staff can spend more time with patients by employing voice navigation, dictation, and editing tools in the EHR.
- DeepScribe:
DeepScribe is committed to ensuring that technology serves us, not the other way around. By utilizing their expertise in AI and ML. Creating a solid documentation solution that completely transforms the patient-provider relationship, DeepScribe believes the moment has come for professionals to be able to concentrate on giving treatment rather than documenting it.
- Augmedix:
By empowering physicians to provide the best care possible for patients, Augmedix aims to rehumanize healthcare. The Clinical Documentation Specialists are the fundamental engine behind their entire operation. Clinical documentation specialists aid physicians in providing excellent patient care by serving as their professional helpers. With the use of cutting-edge technology, Augmedix makes it possible for anyone, anywhere in the world to scribe at any time.
- Augnito:
With 99% out-of-the-box accuracy, Augnito provides quick and simple ways to record real-time clinical data from any device, any place. Augnito increases productivity by 4x faster patient data entry than typing and clinical documentation time savings of at least 3+ hours per day. From any workstation, whether at the office, at home, or while traveling, use their templates, macros, and custom terminology.
- Robin:
Robin is developing a more direct approach to care using a combination of cutting-edge technology and human skill. So that physicians can restore their time and control over their practice. The one-of-a-kind Robin Assistant device ambiently observes doctors’ conversations and captures everything that’s needed to develop medical notes and codes. Robin reduces waiting times throughout their clinic, improves workflow, and creates new value. Behind the scenes, Robin develops comprehensive documentation for doctors at unparalleled levels of accuracy.
- Freed:
A clinical documentation improvement program led by Freed Associates assisted a medical center to improve its publicly reported quality scores through a clinical documentation improvement initiative that resulted in new guidelines for physician documentation in an EHR system. Freed allows providers to transition more smoothly to ICD-10 when expectations for additional specificity in physicians’ documentation increase.
- Ambience:
Ambience’s main product, Ambience AutoScribe, is a fully automated AI medical scribe that smoothly integrates into EMR workflows and captures the subtleties of provider-patient communication in real time into a detailed record. Ambience, which has been adopted by provider groups across North America, cuts the time spent on documentation by 76%, freeing up caregivers to concentrate on what matters.
- Chartnote:
Chartnote is the productivity tool created to bring back the joy of practicing medicine. Templates & speech recognition apps like Chartnote help streamline medical documentation & free up more time for patient care. Chartnote can quickly & easily create accurate and consistent documentation for doctors. Chartnote allows doctors to dictate notes & charts, which are then transcribed into text, saving time & reducing errors.
How to choose the best clinical documentation software?
Clinical documentation improvement (CDI) aims to enhance the accuracy of EHR data for a range of applications, including quality reporting and patient care.
Across a range of healthcare facilities, including hospitals, clinics, and private practices, clinical documentation software can be utilized for patient notes. Health practitioners that work long hours and need to swiftly and efficiently record patient encounters without having to spend hours putting up notes may find it particularly helpful.
- HIPPA Compliance:
The top medical dictation software will show you independent verification that it complies with PHI (Protected Health Information) and HIPAA (Health Insurance Portability and Accountability) rules. Ask the software creator for evidence of an independent audit because their multilingual dictation app will gather electronic PHI that is generated, acquired, utilized, or retained.
- Accessibility:
Undoubtedly, an EMR’s most important aspect is the simplicity with which medical dictation software may be used. Most medical practitioners select dictation software that is user-friendly across all platforms and programs.
- Security:
It is now possible to complete mobile dictation using a tablet or a mobile phone. Data that is shared is kept secure through improved network security.
