Getting Documentation Right at the Source

It's never been more important to deliver excellent patient care, but hospitals are desperate to preserve margins with growing denial issues due to medical necessity documentation issues.
Hospital leaders looking for innovative approaches to CDI, denial management, and medical necessity will find great insight in this research report on a clinically driven revenue cycle.
admissioncare screenshot in ehr


Patients placed in the wrong bed status with improper documentation results in massive revenue loss and patient dissatisfaction.

Physicians can’t keep up with constantly changing criteria needed to admit patients to the hospital, and hospitals spend tons of money and resources fixing bed status issues retrospectively.

We created AdmissionCare to streamline the admission process for physicians by putting the criteria for bed status determinations directly in the EHR.

How AdmissionCare Works

Trusted by Top Health Systems

An ER Physician’s Experience with AdmissionCare

A Hospitalist’s Experience with AdmissionCare

Clinical Documentation Improvement Software

Clinical documentation is a cornerstone of efficient healthcare management. In a world increasingly focused on digital data precision and real-time tracking, clinical documentation improvement software, or CDI software, plays a central role in ensuring documented evidence for every patient’s health journey.

These software solutions streamline doctor-patient interactions and enable adherence to crucial compliance guidelines. Well-structured, meticulous clinical documentation is essential. The scope of clinical documentation is vast, ranging from the patient’s medical history and current health status to prescribed treatments, their effectiveness, and the patient’s response. In this context, clinical documentation improvement software is a dynamic tool that fortifies the quality and accuracy of patient records.

However, the healthcare industry is not limited to one type of software. Various healthcare software, including clinical documentation compliance software and clinical documentation workflow software, govern the operations and administration of any healthcare institute. Clinical documentation compliance software ensures strict compliance with legal and ethical standards. These requirements typically include maintaining confidentiality, guaranteeing precise information recording, and eliminating any possibility of fraud.

With the increasing number of healthcare organizations, insurance companies, and federal bodies scrutinizing records, this software solution mitigates risks and protects the organization’s reputation. On the other hand, clinical documentation workflow software enables streamlined communication of content such as medical necessity documentation between clinicians in a healthcare facility. It provides access to comprehensive patient histories, diagnoses, treatment progress, and more, allowing healthcare providers to deliver cohesive and, most importantly, uninterrupted care.

AdmissionCare, software by EvidenceCare, is a clinical EHR workflow improvement model. The software simplifies admitting a patient to the hospital and significantly reduces clinical interruptions and insurance denials, saving resources and reducing expenditure.

Considering the importance of robust clinical documentation systems and the role of diverse healthcare software, it’s clear that these technologies are critical in contemporary healthcare management. They ensure strict adherence to regulations and promote efficiency, accuracy, and quality of patient care.

Clinical Documentation Integrity

Clinical documentation integrity is indispensable in ensuring optimal patient care, accurate records, and appropriate resource utilization. This integral facet of medicine includes a diverse range of tools aimed at bolstering medical record-keeping and diagnostics.

Governing this domain are the best clinical documentation improvement software vendors who offer cutting-edge solutions to revolutionize contemporary healthcare practices. Vendors such as EvidenceCare provide specialized solutions like AdmissionCare, focusing on clinical documentation integrity software for hospital admissions. They provide physicians with streamlined, timely access to pertinent admission criteria and medical necessity documentation at the point of care, in the Electronic Health Record, or the EHR. This process prevents poor documentation and helps circumvent potential denials and clinical disruptions associated with hospital admissions, driving placement and resource allocation efficiency.

The choice of the right software is essential for every healthcare establishment. This is where the best clinical documentation software vendors shine. Offering timely recourse to medical necessity documentation, they ensure physicians have the necessary information for patient admission.

The right software also helps with hospital bed status placement, avoiding the hassles of re-admissions and associated costs. To illustrate, AdmissionCare auto-categorizes advanced clinical documentation improvement examples for bed status decisions. It integrates seamlessly into the clinical EHR workflow, enabling physicians to make informed decisions regarding hospital admissions and ensuring patient admission to the appropriate level of care. This software eliminates ambiguity and potential administrative pitfalls through its robust clinical documentation improvement solutions.

Clinical documentation integrity is the heart of patient care, impacting every aspect, from resource allocation to patient outcomes. That means choosing the right software is essential. EvidenceCare’s innovative solutions, such as AdmissionCare, demonstrate how advanced computational tools can bolster clinical documentation integrity, optimize resource utilization, and streamline medical operations, truly revolutionizing healthcare dynamics.

Clinical Documentation Improvement Best Practices

Clinical documentation improvement best practices are an essential component of the healthcare sector to streamline operations, optimize resource utilization, and promote quality patient care. Efficient clinical documentation implementation is key to ensuring transparency and accuracy in data, which, in turn, results in substantial improvement in reimbursement rates and supports improved patient care outcomes.

Vital to these transformative practices are robust clinical documentation improvement solutions. Innovations such as EvidenceCare’s AdmissionCare software are impactful solutions, providing physicians with bed status criteria and essential medical documentation required when admitting a patient. This clinical process empowers medical professionals to decide on a patient’s bed status, integrating CDI software in the EHR workflow to mitigate resources and financial drainage related to deficient documentation.

Clinical documentation improvement tools facilitate the documentation process while promoting accuracy and efficiency. Integral to the AdmissionCare software is a set of sophisticated tools that help determine a patient’s eligibility for hospital admission and also support the ongoing audit functionalities to validate the accuracy of the documentation.

Furthermore, investing in comprehensive clinical documentation optimization software can help minimize clinical interruptions, improve patient safety, and enhance revenue cycle management. The AdmissionCare software, designed to optimize the clinical documentation process, goes above and beyond to demonstrate your hospital’s commitment to maintaining accurate EHRs, leading to improved patient outcomes and quality of care.

Often overlooked but equally essential are the clinical documentation improvement resources providing access to a wealth of knowledge that can drive strong clinical documentation programs. EvidenceCare and its software AdmissionCare can serve as an in-depth resource for healthcare professionals committed to ongoing learning and improvement.

From understanding the criteria for hospital admissions to discerning between inpatient and observation criteria, these resources are vital to stay informed of best practice trends within the industry. Clinical documentation efficiency software like AdmissionCare isn’t simply a solution. It’s a pioneering approach to an age-old issue: improving the accuracy, completeness, and reliability of clinical documentation.

Each stride in the investment and application of best practices in clinical documentation drives the healthcare sector further into an era of improved patient care, productivity, and potential profitability. Marrying the principles of clinical documentation improvement with innovative software solutions shines a light on the path toward transformation in the healthcare sector.

CDI Software for Hospital Admissions

AdmissionCare, a unique CDI software for hospital admissions, is a key innovation from EvidenceCare. It delivers comprehensive admission guidelines and medical necessity documentation straight to physicians. The seamless integration into the EHR system makes the process efficient, sparing hospitals from unnecessary denials and clinical setbacks associated with inadequate documentation.

Clinical Documentation Improvement (CDI) is not only about documentation but also significantly focuses on the quality of patient care by ensuring the accurate representation of a patient’s clinical status. AdmissionCare, as an eminent clinical documentation reimbursement software, enhances the quality of documentation, ensuring payment for services rendered. It operates at the point of care and guides the admitting physician toward improved documentation for hospitalization billing, reduced denials, and increased operational efficiency.

CDI for medical necessity is part of the admissions process. Medical necessity refers to a concept that means a physician considers certain medical services reasonably necessary. AdmissionCare equips health professionals by providing automated criteria for medical necessity during the patient admission process, mitigating discrepancies that could surface during post-treatment audits.

AdmissionCare could be considered a CDI software for emergency departments. Quick and critical decision-making is integral to emergency departments. AdmissionCare actively assists physicians in determining the right care decision for patients presenting to emergency rooms. It provides real-time admission criteria information, accelerating clinical decision-making and ensuring appropriate documentation.

Lastly, AdmissionCare serves as an effective CDI software for inpatient care. Ensuring a patient is assigned the correct admission status is complex, given the intricate rules and criteria involved. Yet, it’s crucial for proper reimbursement and compliance.

AdmissionCare proves an invaluable tool in this regard, providing physicians with the exact level of care criteria directly at the point of care, leading to appropriate bed status assignments. Thus, AdmissionCare is shaping the future of clinical documentation improvement and significantly impacting entire hospital systems. Its diverse functionalities and emphasis on accurate, compliant, and efficient medical documentation make it an indispensable tool in today’s healthcare context.

CDI Software with Integrated Clinical Decision Support (CDS)

The significance of robust clinical documentation improvement (CDI) software with integrated clinical decision support (CDS) is steadily rising. This type of software enhances the precision, relevance, and timeliness of patient data found within electronic health records (EHR), thus paving the way for improved clinical outcomes, efficient resource allocation, and streamlined administrative workflows.

EvidenceCare, with its innovative AdmissionCare software, seamlessly integrates with the EHR, providing clinicians with crucial admission criteria and medical necessity documentation at the point of care. By avoiding unnecessary administrative burdens linked to poor documentation, hospitals can save significant resources and financial contributions.

Exploring this further, let’s look into the integration of CDI software in the EHR. Unquestionably, electronic medical records (EMR) systems in healthcare have been revolutionary, streamlining data management and improving patient care. When paired with comprehensive CDI software, it becomes easier to capture pertinent patient information that’s reliable, easily accessible, and actionable.

Through platforms like AdmissionCare, physicians can unlock the full potential of their EHR by acquiring real-time insights that help solve problems and enhance decision-making. Additionally, CDI software with integrated clinical decision support (CDS) is an important consideration. CDS tools embedded within CDI solutions offer real-time, patient-specific clinical advice that directly influences the quality of care delivery. Whether it’s flagging potential drug interactions, reminding clinicians about preventative care measures, or even recommending specific diagnostic procedures based on a patient’s case history, such integration makes CDI software indispensable in contemporary healthcare.

Despite the many options available, choosing the ideal solution among different clinical documentation improvement vendors can take time and effort. Key factors include interoperability with your existing EHR system, ease of use for staff, clinical impact, and, above all, patient outcomes.

Based on this review, software like AdmissionCare is an excellent choice, encapsulating all these attributes and more. The horizon of healthcare is ever-evolving, and CDI software armed with integrated CDS features is no longer a luxury but a necessity. With solutions such as AdmissionCare optimizing EHR workflows and empowering clinicians, hospitals can look forward to a seamless, efficient, and cost-effective future in patient care.

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