Clinical Documentation

Improve clinical documentation, organization-wide

Orion Health's web-based Clinical Documentation solution assists in the creation and transmission of a wide range of legible and accurate medical documents, with a high degree of automation.

Clinical Documentation can be used to produce and manage a broad range of medical documents, including Admission Notes, Patient Progress Notes, Allied Health Notes, Nursing Assessment Forms, Pharmacy Updates and Discharge/Transfer Summaries.

Using Clinical Documentaiton, mandatory documentation tasks can be woven closely into clinical processes. Documents can be initiated automatically, and data from a wide variety of existing information systems can be combined within documentation to improve accuracy and completeness.

Improved accuracy and clarity of documentation

The generation of clear, typed documents using Clinical Documentation reduces the chance of confusion or medical error associated with manually generated documentation.

Rapid recall of existing documents

All documents created using Clinical Documentation, along with documents residing in systems throughout the organization (for example, scanned documents, digital images, lab results and other patient documentation) can be rapidly called up and reviewed within the Clinical Portal.

Integrating documents into the Electronic Health Record (EHR)

Documents created with Clinical Documentation can be easily integrated within the patient's Electronic Health Record, allowing documents to be securely shared and viewed by authorized health providers across a facility, organization or an entire region.

Pre-population of data streamlines documentation process

Clinical Documentation can automatically generate a "mostly complete" document using data sourced from other hospital systems and previously created documents.

For example, administrative details can be sourced from an existing ADT/PAS system, relevant lab results can be pulled directly from a laboratory system and current medication details from the pharmacy system.

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