The Clinical Module comprises all functionalities required for a complete electronic health record (EHR). Because ClaimTrak is a comprehensive, paperless solution, the client chart in its entirety can be accessed from any agency computer terminal given that the user has the appropriate security access.
There are hundreds of clinical forms to choose from in the Clinical Module. These forms include multiple styles of Assessments (Psychiatric, Psychosocial, Lethality, Nursing, Vitals Log, etc), Treatment Plans, Treatment Updates/Reviews, Progress Notes, Discharge Summaries, Medication Administration Logs, just to name a few. ClaimTrak also provides custom development services to modify or develop any form to meet the specific needs of our customers. Clinical forms are user-friendly in design and function.
From the electronic chart, users can access any record (current and historical registrations), complete all documentation including progress notes, view and scan external documents, conduct chart audits and view applicable client information at a glance.
ClaimTrak is a single-point of entry data system, i.e. once information such as demographics, insurance, referral source, etc. is entered during initial referral, all data elements flow through the entire software package. Each Referral screen is customized to capture the customer’s specific data elements.
Intake / Enrollment, Assessments and Closures
Clinical forms are developed to meet agency specific requirements. Built-in edits ensure the validity of data entry. The system allows for corrections and changes to intakes and assessments as well as clinical updates. One example of an edit that may appear on a clinical form to verify the data fields are consistent and complete include red and green “light prompts” at the bottom of the screen. A green light at the bottom of the screen indicates the field has been completed. The red lights indicate the fields that have not yet been completed. The user can see at a glance if any fields have been missed.
Treatment Planning & Progress Notes
Customized treatment plans and progress notes are available in the ClaimTrak system. Functionality such as goals and objectives from the client’s current treatment plan may be automatically available to select on the progress note.
The Staff Home allows the clinician to access and manage every aspect of the caseload. From the Staff Home, the clinician may view and manage the following:
ClaimTrak supports electronic signatures on all applicable forms. Multiple electronic signatures are also allowed were needed (e.g. clinician, client, supervisor, etc.)
ClaimTrak offers multiple ways of capturing electronic signatures including: