Sigmund Software, LLC



Thursday, December 04, 2008

Medical Documentation

Intake Tracking
Patient Information
Clinical Documentation
Medical
Electronic Prescribing
Scheduling
Staff Information
Billing and AR
Electronic Data Interchange
Quality Assurance
Document Management
Ad Hoc Reporting
System Integration


MEDICAL DOCUMENTATION

Sigmund™ offers comprehensive functionality designed to meet the needs of all of your medical staff. Highly integrated, work-flow oriented modules streamline assessments, vital signs monitoring, prescribing, order entry, medication administration and more. Nurses and doctors benefit from multiple timesaving and compliance-oriented features, including features such as batch order entry, electronic prescribing and medication titration templates.

Medical Documentation

Selected Features Summary
  • Assessments and Vital Signs
    • Perform and report on medical and nursing assessments
    • Create user-defined History and Physicals as well as other assessments
    • Automatically import assessment information into progress notes and summaries
    • Track biometric information: BP, Pulse, respirations etc.
    • Track glucose levels
    • Track Blood Alcohol levels
    • Track heights and weights
    • Track patient allergies and fully integrate with prescribing and administration modules
  • Computerized Physician Order Entry (CPOE)
    • Document all internal and external medical orders and precautions and  associate patient alerts
    • Create user defined orders for medications, lab work, consults etc.
    • Notify physicians and queue labs, consults etc. for viewing
    • Record verbal, telephone and written orders
    • Create batch orders
    • Enter orders and queue for physician approval
    • Track clinical precautions, privileges and visitation orders
  • Prescribing / Pharmacy Management
    • Record, Track and report on all current and historical medications prescribed
    • Send Electronic prescriptions directly to pharmacies or print to watermarked Rx paper
    • Track medication education information
    • Establish titration schedules to avoid redundant data entry
    • Automatically populate the Medication Administration Record in real-time
    • Capture comments and reasons for medication start, change and discontinuation
    • Automatically write and renew prescriptions refills
    • Enter prescriptions and queue for physician approval
    • Automatically generate narrative progress notes when medications are changed
    • Track, view and search entire medication change histories
    • Manage multiple pharmacies across patients and continuum of care
    • Track and manage multiple medication distribution methodologies (e.g. blister-packs, vials etc.)
    • Empirically track and report on all patient symptoms filtered by medication dosage and start and end date.
  • Medication Administration Record (MAR)
    • Track all medications administered
    • Record is automatically populated based on prescription entry with optional approval process
    • Model complex dosing regimes with sophisticated logic to prevent double dosing, premature administration, administration outside of windows of time etc.
    • Filter and order by name, site, program building etc. to speed administration
    • Track medication education
    • Track medications self-administered, administered off-site etc.
    • Track medication side-effects, comments, partial doses etc. and notes
    • Secure patient and staff signatures and viewing multiple patient identifiers
    • Empirically track and report on all patient symptoms filtered by medication dosage and start and end date.

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