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Product Overview |
Clinical Documentation |
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Wellsoft EDIS allows for fast and complete clinical documentation through the use of dynamic complaint specific templates. Pop-up menus are customized for each hospital to enable quick entry of information with the ability to free text at any given point. Wellsoft EDIS can bring forward patient information from previous visits to populate fields in the current record. Charts from previous visits are immediately available to support patient care decisions. Documentation for ancillary services is also available for disciplines such as Respiratory Therapy, Social Services, Case Managers and Psychiatry. Copies of the chart can be sent electronically to any HL7-compliant system such as a CDR or hospital wide EMR. Triage Custom-configured screens for triage and assessment can be as brief or complete as the department wishes. All triage data such as patient information, presenting complaint, acuity, vital signs, and initial assessment can be captured. A unique triage impression feature provides an extensive list of clinical elements to better communicate patient presenting illness and expected course of treatment. Nursing Documentation Easy-to-use templates facilitate complete nursing documentation. Pop-up menus provide fast documentation of clinical treatments, clinical assessments, procedures and interventions. Templates are easily customized to support the hospital’s standard of care and requirements such as Fall Risk Assessments are included. Access to all POC tests is streamlined in a single location in the patient record and provides one source for all POC information. Physician Documentation Intuitive complaint-driven templates prompt the physician for all required documentation elements (HPI, ROS, PMH, PSH, Physical Exams, Procedures, Progress Notes, Decision Making) using pop-up menus and custom pick lists. Free text can be added at any time. Any method of data input including voice recognition or handwriting recognition tablets can be used. Ancillary Services Documentation Versatile multi-discipline templates are provided for ancillary services such as Respiratory Therapy, Social Work, Chaplain, Psychiatric and Case Management. Templates are customized to meet any hospital specific documentation need. Special Needs Patient Care Plans Store a longitudinal record of patient specific protocols for special patients, typically those with chronic issues, such as sickle cell anemia, migraines, and pain management. Links notify the user upon registration of an identified special patient. Wellsoft maintains individualized “care plans” for these patients enabling physicians to maintain continuity of care by being informed of the patients’ history of treatment and any other pertinent information. Intake & Output Table/Calculator Wellsoft's fluid intake and output table allows clinicians to electronically document patient fluid (e.g., blood, urine) intake and output data supported by automatic total fluid balance calculations.« return to Product Features |
