CLINICAL DOCUMENTATION
Sigmund™ fully computerizes the case record from admission to discharge, including Assessments,
Individual and Group Progress Notes and Treatment Plans. It provides tools for monitoring timeliness and
quality of documentation. It supports a range of flexible outcome management and aggregate reporting
strategies to assess the efficacy of various treatment approaches. Sigmund Software manages your
documentation to achieve all of your organizational goals, and enables clinical staff to effectively
manage their departmental operations, resources and schedules. Automated document reviews, task assignments
and electronic signatures streamline the documentation process. Integrated reporting and oversight
features specific to clinical documentation introduce a new level of accountability and efficiency.
Sigmund’s ability to streamline workflow and automate documentation increases provider productivity,
decreases patient waiting time and dramatically improves the flow of accounts receivable. Sigmund’s
makes adoption of the EMR easier by allowing organizations to continue to use pre-existing forms
and assessments by configuring them into the application as is.
Selected Features Summary
Diagnosis Information
- Quickly add a diagnosis using a user friendly drop down list of current DSM-IV categories with corresponding diagnostic codes
- Identify primary, secondary, rule out or traits for diagnostic establishment
- Severity and course specifiers allow clinicians to document more specific information regarding diagnosis and history
Assessmets
- Maintain and modify assessments with a full user-maintenance function
- Utilize decision support features to ensure continuity and appropriateness of care
- Conduct complete intake and update assessments
- Automatically generate narrative admission summaries
- Enter data by computer screen or hand held device
- Administer Assessments to patients in a secure, unattended mode
- Make Diagnostic Recommendations based on your assessments; estimated length of stay, diagnosis, recommended treatment objectives etc.
- Detail Admission Orders based on your assessments
- Automatically import assessment information into forms, progress notes, discharge summaries etc.
- Create assessments or use Sigmund standardized assessments to:
- Record Clinical / Biopsychosocial Assessments
- Enter Standardized Psychometric Scores
- Administer Public Domain Assessments
- Conduct Satisfaction Surveys
- Record Outcomes
- Conduct After-Care Surveys
- Assess patients´ Presenting Problems, Risk for self-injury and harm to others, Mental Status, Legal Status,
Treatment History, Health and Physicals, Neurological and Biometrics screenings, Psychosocial History,
Vocational Strengths and Employment Histories, Alcohol and Drug Use Histories, Social Service Needs and more
- Easy to use assessment administration allows users to select from a pre-defined drop down menu of responses, or free text comments and observations
- Check boxes, and drop down menus in addition to free text boxes allow users to administer evaluations and assessments quickly and thoroughly
- Score assessments to identify appropriate level of care and treatment approach
- Aggregate assessment responses over time to identify treatment progress, mental health indicators, medication compliance etc.
- Automatically attach interpretive summaries to assessments to communicate recommended interventions and next steps
- Require patient/staff/supervisor signatures for recommended assessments with a comprehensive document security screen.
Allow your organization to aggressively make changes to required documentation to comply with changing regulatory requirements
Treatment Planning and Summaries
- Create individualized treatment plans in as little as 10 minutes
- Prepare initial and updated treatment plans quickly and efficiently that document intake information, strengths,
problem areas, diagnosis, goals, objectives, interventions, responsible staff, target dates,
length of stay estimates, discharge options, and more
- Recommend problems based on outcome or assessment information that is captured
- Recommend goals, objectives and interventions based on pre-defined system options
- Recommend scheduled activities and orders
- Incorporate detailed discharge planning information
- Plan types can be designed by discipline, program or service such as Nursing Care Plans, Individual Education Plans and Behavior Plans
- Design, implement and measure the outcome of your own critical pathways
- Effectively describe the medical necessity of treatment
- Create treatment planning templates for specific diagnoses, problems or programs
- Conduct treatment plan reviews
- Automatically generate narrative summaries for admission, discharge, or progress review for all patients based on information that has already been captured in the medical record
- Auto fill summaries with demographic information, diagnosis, continuing care plans, treatment plan problems and objectives, medications, and treatment recommendations
- Easily attach progress notes, treatment team, drug test results to summaries
- Summaries can be automatically generated, while at the same time allowing designated staff to manipulate summary on the fly and add additional information
- Review data trends reflecting patient progress
- Print comprehensive treatment plans, treatment plan implementation reports, admission, transfer and discharge summaries
Progress Notes
- Create an electronic record containing all progress notes
- Create individual and group progress notes
- Create specialized progress note types including rich text and PDF documents
- Record progress notes by treatment objective
- Audit staff compliance with progress notes standards and quotas
- Audit completion of notes required for specified service events
- Sign notes with electronic signatures
- Search for progress notes by multiple variables; author, patient, treatment objective, type of progress note
- Generate stock phrases, introductions and templates for progress notes
- Import demographic, assessment, clinical and medical information into progress note narratives
- Create templates for "auto" progress note generation
- ire and link progress notes to service delivery and billing information
- Prompt for progress notes when system events occur (e.g. appointment delivered)
- Automatically generate progress notes that document system activities (e.g. medication changes, admissions, discharges etc.)
- Employ sophisticated security options to control amending, appending etc.
- Queue progress notes for supervisory review
- Identify multiple signatures and co-signature requirements
Specialized Clinical Documentation Tools
- Create behavior intervention plans
- Track substance history usage
- Tracks drug testing results
- Access Medications, Progress Notes, Treatment Plans, Scheduling and more from the Clinicians Notebook – a simple real world representation of a day planner integrated with all core clinical information
- Manage schedule, tasks, messages, clinical documentation and more from the Clinicians Homepage – a highly functional, task oriented outlook style interface
- Send patient alerts manually or based on diagnoses, assessment responses and/or scores
- Conduct, assign, track and report on electronic chart reviews
- Create organizationally defined automated quality assurance tasks which appear at end user home screen. Automated tasks can mirror local, state, HIPAA, CARF, JCAHO documentation requirements
- Configure organizationally defined forms and assessment directly into the application or make use of industry standard assessments
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