TouchWorks EHR

Clinical Documentation

Managing a clinical practice today involves paper and lots of it. TouchWorks offers healthcare organizations an easy and cost effective pathway to a paperless chart.

Even the most effective paper chart has limitations in terms of quickly assembling, consolidating, and accessing clinical data. Managing the creation, completion, and distribution of documents is a significant burden for both clinicians and their staff. Dictation and transcription management can be extremely time-consuming and costly for physician practices.

TouchWorks makes structured, template-driven documentation a by-product of providing care, supporting clinical note creation, inbound transcription, structured data entry, and clinical correspondence. Physicians may use a combination of structured data entry, textual data entry, citation of existing clinical data, and direct dictation using dictation markers.

TouchWorks provides multiple options for creating clinical notes:

  • Templates
  • Dictation
  • Document Management
  • Scanning
  • Transcription

Templates
TouchWorks offers templates for structured data entry of notes with narrative generation of clinical notes and "Intelligent Prompting" including structured clinical terminology based on MEDCIN® database of over 200,000 medical terms and mapping to ICD-9 diagnosis codes. TouchWorks Note also includes a spell checker with medical terminology and an E/M calculator, which includes defaulting of structured data into the E/M Coder, which generates E/M coding recommendations based on the level of care that was documented.

Dictation
TouchWorks offers physicians a quick and easy way to dictate, review, and submit medical documents from virtually anywhere at anytime streamlining workflow and reducing document management time from weeks to hours. Restoring mobility and convenience to the physician, TouchWorks combines the convenient functionality of a handheld digital recorder with the operational efficiency of a telephone dictation service. Using the latest in Pocket PC technology from Microsoft and the digital dictation capabilities of a Tablet PC or handheld iPAQ PDA technology from HP, TouchWorks Document offers the functionality of a handheld digital voice recorder for use by physicians at the point of care.

Document Management
The clinical data repository and clinical document management functionality of TouchWorks streamlines workflow for physicians, as well as for clinical and administrative support staff, resulting in greater efficiency and reduced potential for error. TouchWorks supports clinical dictation, medical transcription, and clinical correspondence with a longitudinal, fully indexed clinical document repository.

Document Imaging/Scanning
TouchWorks delivers the paperless office today by enabling clinical document scanning, indexing, and viewing. While some solutions only incorporate parts of the record at a time (or worse, cannot incorporate some parts at all), physicians using TouchWorks can store and access all types of documents and images, including correspondences and other paper documents, as part of a longitudinal clinical data repository and comprehensive EMR.

Transcription
TouchWorks enables in-house transcription-increasing the accuracy and efficiency of dictating and transcribing documents in a cost-effective manner. TouchWorks provides physician practices with a convenient way to route and listen to dictation, transcribe dictation using all of the features of Microsoft Word, and electronically file completed medical documents directly into the clinical repository, thus streamlining workflow and reducing document management errors.

Benefits

  • Reduces cost
  • Improves documentation quality
  • Improves access to information
  • Improves security
  • Improves productivity and efficiency
  • Increases accuracy
  • Reduces errors
  • Increases revenue