Practice Management Technologies

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Clinical Record
 
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Automated Clinical Record

Designed by therapists and case managers, Practice Management Technologies' Clinical Record is a fully integrated module which provides the clinician, case manager, ACT worker, residential services worker, nurse, and physician with a state-of the-art tool which focuses on the client´s treatment goals and objectives.

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Clinical Record provides an efficient system to document the treatment process from the point of initial contact; through the intake assessment; treatment plan development including goals, objectives and interventions; progress notes; status reviews; and termination of treatment. Utilizing the Person Centered Planning process, staff can document who participated in the care conference, and the strengths and needs of the consumer, ultimately resulting in the development of goals, objectives, and interventions.

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Assessments are completed and documented using a combination of check boxes and narratives. Special assessments for suicide lethality, homicide lethality, potential for violence, life skills, and substance abuse are linked to the main assessment and are incorporated as necessary or required. A comprehensive mental status evaluation is included as a standard tool for the clinician to assess the overall level of functioning of the client. Assessments can be exported to Microsoft Word for editing and printing.

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Progress notes are available for individual or group sessions. Group session notes can be created using a general note for all group members and then individualized for each group member. Progress notes are linked to specific goals and objectives as required by JCAHO, COA, and CARF guidelines.

PMTech has three versions of it's Clinical Record; to provide you the features you need at a price you can afford.

 
Clinical Record 1
Clinical Record 2
Clinical Record 3
Standard Features
Behavioral Screening
YES
YES
YES
Clinical Assessment
YES
YES
YES
Closing Summary
YES
YES
YES
Group Progress Note
YES
YES
YES
Individual Progress Note
YES
YES
YES
Intake Screening
YES
YES
YES
Mental Status Exam
YES
YES
YES
Plan of Service
YES
YES
YES
Plan of Service Review
YES
YES
YES
Additional Assessments
Case Management
 
YES
YES
Homicide
 
YES
YES
Life Skills
 
YES
YES
Potential for Violence
 
YES
YES
Substance Abuse
 
YES
YES
Suicide
 
YES
YES
Nursing
   
YES
Psychiatric
   
YES
Medication Tracker
   
YES
Allergy Tracker
   
YES
Clinical Events
   
YES


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