Electronic Health Record

The Electronic Health Record is a consolidated group of applications that provide easy and intuitive access to the patient's electronic treatment record through a single interface. Electronic Health Record allows clinicians at different locations to view a clinical record simultaneously. No more having to track down a paper chart! Additionally, it has been Valley Hope's experience that the learning curve for new clinicians is typically short. New clinical employees usually become productive with the Electronic Health Record very quickly. There are several modules included in the Electronic Health Record:

Progress Notes

The Progress Notes module of the Electronic Health Record allows for the easy and simple documentation of patient interactions, whether it be nursing records or individual or group counseling sessions. Clinical editors have the ability to designate note captions and goal captions as well as create note templates that can be made available for easy record keeping. Utilization review notes are also completed in the chart which provides easy access to the kind of information needed to effectively communicate with insurance companies. Notes can be easily filtered by type, caption or word search on the note itself to make it simple to find specific information.

Treatment Plan

Treatment planning in the Electronic Health Record software eases the burden of producing paper documentation of treatment plans. Clinicians have the ability to create their own problem statements and interventions and a plan library that includes interventions for most common problem statements is also available and maintained by clinical supervisors. Multi-disciplinary case conference review forms can be generated through the software. The treatment plan software also is coordinated with progress notes software to include problems identified in the treatment plan as note captions in the patient progress note records.

Admissions Assessment

The Admissions Assessment in the Electronic Health Record software allows for clinical supervisors to have complete control over the organization and information deemed necessary for a complete patient assessment. By allowing for electronic record keeping, staff are able to view information that has been asked by other staff members and eliminate some of the duplicate record keeping and information gathering at the time of admission. The admissions assessment consolidates all of the separate elements as designed by the clinical supervisor at the location into one complete assessment.

Discharge Summary

The Discharge Summary in the Electronic Health Record uses the same clinical supervisor editing functions as the admissions assessment to create a discharge summary individualized by the treatment center.

Group Progress Notes

Group Progress Notes allows the clinician to access one screen to chart on a group of patients. The notes can be tailored and individualized appropriately for each patient and when the clinician signs the note, the records are added to each patient's individual patient record eliminating the need to open each individual record and chart one at a time.

Medication Administration

The Medication Administration Record in the Electronic Health Record (MAR) module is currently in design.