Hospital management medical records applications

Hospital and clinical environments

Medscribbler Enterprise is a single source for viewing all relevant patient information—in all areas of clinical care— from within a large facility to the whole health care delivery system. Complete visit histories are electronically stored for each patient over the course of an entire lifetime.

Medscribbler Enterprise allows every aspect of care to be documented in a quick entry mode from handwriting to voice to keyboard. The information is in a real-time basis, updating tests, procedure and investigations immediately as they happen with access to those involved in the patient care.

Medscribbler Enterprise can accept information from most other systems, even legacy systems without handwriting. A Health Level Seven, HL7, interface can be made for any aspect of a current system that may want to be kept.

Highlights

Medscribbler Enterprise is designed with care providers and their many tasks in mind which means entry and retrieval of information in a format that works at the speed care providers do. The EMR's efficient and intuitive functions require little or no training because the software is made to the care giver's normal work flow. Work flows are not forced to meet "point-and-select" or "point and click" limitations.

The EMR provides highly accessible patient data and features:

• Handwriting notes and annotation
• Historical and demographic patient data
• Triage and current care
• Electronic order placement and signature
• Smart cards and RFID tracking
• Outpatient care givers integration

Standard Current Care Features

Medscribbler gives care providers instant and immediate access to a comprehensive, computerized record of current patient care and clinical procedures. This record includes:

• Test results
• Medications
• Vital signs
• Patient care (nursing) documentation
• Orders
• Reports

Standard Historical Features

• Medical history and test results
• Previous visits
• Demographics

Standard Community Network Feature

Medscribbler is actually useful for outpatient data because the simplicity of use with handwriting encourages physicians, nurses and therapists to be part of the system. Information can flow from many care center locations including:

• Physicians' offices
• Outpatient surgical centers
• Nursing homes
• Home health care agencies
• Satellite labs
• Rehabilitation centers
• Health Maintenance Organizations (HMOs)

Standard Administrative Data

The EMR includes all administrative data possibilities. This data includes:

• Complete demographics
• Insurance information
• Diagnostic and procedure code assignments
• Photographic and smart card identification
• Formulary maker