Clinical Records for LTC

Electronic Medical Record (EMR) for Long Term Care

Our Clinical Records Systems is an easy-to-use and efficient way to maintain a comprehensive Electronic Medical Record (EMR) on each resident. You can access the many parts of a resident’s EMR from a single screen or from well-organized menus.

This library-based system allows you to:

Record EMR information in formats required by government agencies.
Create and standardize information in words that you understand.
Select and edit available responses rather than continually re-describe similar events and conditions that tend to recur.
Sort information for management and statistical reporting.

Hi-Tech provides EMR capability in two versions of the Clinical Records System:

Nursing Care
Residential Care and Assisted Living

Both Systems record the following information in each resident’s EMR:

Face Sheets--demographic details identify a resident throughout the system.
Physicians Orders--produce Medication and Treatment Administration Records (MARs and TARs).
IMAR Electronic Medication Administration--paperless medication administration.
Flow Sheets--define and track daily care to be given to each resident.
Kardex Sheets--a 1-page snap-shot of each resident’s needs.
Calendars--schedule residents’ events, activities, order renewals, appointments, labs and more.
Vitals--record blood pressure, pulse, temperature, respiratory rate, O2 saturation, pain scale, glucose level, height, weight, edema scale, intake and output. Access recorded vitals from other areas of the EMR.
Clinical Assessments--assess levels of risk and acuity of various health conditions.
Activities/Events Tracking--record attendance at activities and the occurrence of events that you define.
Inoculations administered to residents.
Notes--document residents’ behavior, conditions, activities, status, etc.
MDS and state-level assessments--assess residents for care planning and insurance payment.
Case Mix and RUG calculation for reimbursement by Medicare, Medicaid and commercial insurance.
Care Plans/Service Plans--define problems, goals and approaches that address resident’s specific needs.
Quality Indicators and Survey Reports--assess the care given to your residents and prepare reports for surveyors.
Quality Assurance--extract and compare specific types of information.
Stay Histories--maintain billing details for each stay in the facility.
Therapy Systems--schedule Rehab (PT, OT, ST) and Respiratory Therapy and track charges.
Resident Referral--track and assess prospective admissions to your facility.