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Documentation software: Which one are you using and why?
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Documentation software: Which one are you using and why? - May 5, 2006 7:27:00 AM
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bhenchodh
Posts: 39
Joined: April 4, 2006
Status: offline
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I met a new clinic owner at a meet and great last weekend and he mentioned that he is using plain old microsoft office 2003 for documentation, excel and word to be specific. We discussed documentation security but I was not convinced. Any opinions out there? I revisited APTA documentation guidelines, and state of NJ guidelines. Even though very verbose they are lacking specific guidelines for computerized documentation software specifications. Now I don't know how much HIPAA compliant MS Office is, but my colleague said that MS password protection on files, is superior to third party software. All this discussion has made me curious about whcih software do you guys use, if any? Thanks in advance and I also told this guy to read this post.
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Re: Documentation software: Which one are you using and... - May 5, 2006 9:53:00 AM
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Jeffre
Posts: 130
Joined: August 18, 2005
From: Lafayette, LA
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I have not used this but it looks pretty cool. It is also linked to evidence based resources so you can cite your reasoning for treatments:
http://cedaron.com/cedaron/aptaconnectdatasheet1.htm
_____________________________
"You are as well as your insurance company is willing to allow."
- Dr. Hibbert
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Re: Documentation software: Which one are you using and... - May 5, 2006 12:57:00 PM
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drbuddy
Posts: 429
Joined: July 30, 2005
From: Pennsylvania
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I am thinking about using MS Word myself. As long as the files and/or computer is password protected, I dont see any problems. Perhaps someone else here knows more and can correct me.
What are your specific concerns regarding security? Are you talking about when used over a network?
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Re: Documentation software: Which one are you using and... - May 6, 2006 2:15:00 PM
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jma
Posts: 2414
Joined: August 24, 2000
From: NY
Status: offline
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The APTA endorses, "ReDoc", found at [URL=http://www.rehabdocumentation.com]www.rehabdocumentation.com[/URL]
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Re: Documentation software: Which one are you using and... - May 8, 2006 5:31:00 AM
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bhenchodh
Posts: 39
Joined: April 4, 2006
Status: offline
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One of my concerns is with updating medical records. For instance, you can go and make changes to your daily notes at anytime in the past and no one can tell if you changed your notes. There is no timestamp for all the changes. How will that impact your validaty in court if your records are reviewed? Do other softwares allow this tracking feature?
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Re: Documentation software: Which one are you using and... - May 9, 2006 3:01:00 PM
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ptisme
Posts: 3
Joined: September 22, 2005
Status: offline
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I use the Advantage Software. It is quick and easy. It creates my Evals for me in Word documents, that I can customize to highlight different findings. [URL=http://www.advantagesoftware.com/pt]www.advantagesoftware.com/pt[/URL]
It also handles all my billing and scheduling.
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Re: Documentation software: Which one are you using and... - May 10, 2006 4:33:00 AM
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drbuddy
Posts: 429
Joined: July 30, 2005
From: Pennsylvania
Status: offline
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AHA,
I intend to make a back up on CD daily. That will allow a paper(less) trail that I can point to if there is ever a question of changes. You have to back up files everyday anyway in case of a computer crash, so just save the back up file under a different name each day. Also, once it is burned to a CD or DVD, it cant be changed.
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Re: Documentation software: Which one are you using and... - May 11, 2006 3:10:00 AM
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ehanso
Posts: 355
Joined: September 14, 2004
From: Minnesota
Status: offline
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We use Redoc with the ESIG module and after a bit of a learning curve it works well. Each time the document is signed it is time and date stamped. It is possible to change the document but the person who opened it can be tracked. If it is opened and re-signed, it is time and date stamped. This makes it difficult to go back and ramdomly change the information anonymously.
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Re: Documentation software: Which one are you using and... - May 11, 2006 11:03:00 AM
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chiroortho
Posts: 655
Joined: February 18, 2004
Status: offline
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Using WritePad (Addison Health Systems, Inc.), you can lock your notes so that any changes at a later date have to be posted as such, as an addendum.
_____________________________
Greg Priest, DC, DABCO
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Re: Documentation software: Which one are you using and... - May 12, 2006 8:26:00 AM
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nmueller13
Posts: 6
Joined: January 21, 2006
Status: offline
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Have you looked into Therawriter from Hands on Technology? I've been doing some research on software too and so far I like them the best. You can purchase the suite (includes documentation, accounting, billing, office management and tracking stuff - TheraOffice) or just the documentation software. It has a PDA feature so you can document on that while you're treating. The samples they sent me looked very professional and the documentation allows for you to actually type in the note (not just drop down lists of preselected text). The company was started by a PT and a software enginer. I haven't used it personally so can't say it works great but from the info and their website it seems easy to use. Maybe somebody reading this has used it and can give us some real life input.
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Re: Documentation software: Which one are you using and... - May 17, 2006 5:30:00 PM
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Lucien
Posts: 13
Joined: September 21, 2005
Status: offline
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Thera writer is the way to go. we have been using them for 2 years and are very please with the working relationship with the owner for any quesitons. It allows you to do notes, HEP, bill, track referral renewals and much more. We are constantly learning the benefits and have checked into others, but feel for the price, quality and commitment of the owners it is worth a look from any clinic.
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