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PHYSICIAN Communication between physicians and nurses is critical to efficient and safe patient care. CMR©’s clear and concise flagging system on the patient “White Board” enables clinicians to monitor the progress of patients in the Emergency Department by simply glancing at the white board. The major challenge for an Electronic Health Record in terms of the actual documentation process is usability. Our clients praise us on our ease of use. With the CMR© Information System, documentation is captured as a user moves from our KwikClix™ screens to additional screens in a given section. When utilizing CMR© physicians responsible for their own billing have seen a significant increase in charge capture resulting from the comprehensive documentation produced. Our E&M LOS tool provides quick reference to documentation requirements. Feedback on our Validation screen directs the clinician to any specific areas where further documentation may be considered or if required documentation such as order verification or diagnostic resulting is lacking. This significantly improves compliance, core measure reporting, Enhances patient care and reduces Professional Liability Risk. In addition to our user-friendly, traditional and intuitive layout, speed of documentation is supported by incorporated features such as our user-defined Physical Exam WNL findings and the Prescription Writer where one can easily create and save Favorites. Our Discharge Instructions, accessible by all clinicians, include over 1250 titles and can be quickly edited for a single patient or saved to Favorites for future use. Follow-up recommendations are clear and serve as another Risk Management tool. Another example of CMR©’s ease of use is our Physical Exam screen. The user quickly selects which systems are normal or other common findings on the initial KwikClix™ screen. When needed, the user can then navigate via links to one or more comprehensive text-based or KlikMan™ image-based Physical Exam screens to create specific findings. With one click of the Save To Chart button, all of the text created rolls onto the chart. Quality of care demands that we keep patient safety as our foremost goal. The top section of each chart displays information including patient identification, location, Chief Complaint, Vital Signs and any Allergies. A flashing Presenting Vitals button on the patient’s chart and a flag on the white board instantly alert the clinicians to any out of range Vital Signs.
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