How to Close a Pregnancy Episode in Epic:
In Epic, closing a pregnancy episode involves: initially discharging the patient from the hospital after delivery, then selecting “Close Pregnancy” under the “More Options” tab in the patient’s chart. This action will end the pregnancy episode and create a summary document that includes prenatal, labor, and postpartum information. Additionally, close any open orders or tasks related to the pregnancy, and complete all necessary documentation and discharge instructions.
Clinical Encounters: The Foundation of Epic Charting
When it comes to the intricacies of healthcare documentation, Epic Charting stands tall as a comprehensive and user-friendly electronic health record system. At its core, Epic Charting revolves around the concept of clinical encounters, the pivotal foundation on which patient care and record-keeping seamlessly intertwine. In this insightful exploration, we delve into the diverse world of clinical encounters, their purpose, and their crucial role in shaping the patient’s health narrative.
Types of Clinical Encounters:
Clinical encounters encompass a wide range of interactions between healthcare providers and their patients. Each encounter serves a specific purpose and contributes valuable insights into the patient’s health journey. Let’s unravel the key types of clinical encounters:
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Initial Visit: This sets the stage for the patient-provider relationship, a comprehensive evaluation that captures the patient’s medical history, current concerns, and treatment plan.
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Follow-up Visit: As the patient progresses through their treatment, follow-up visits monitor their progress, adjust medications, and address any emerging issues.
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Urgent Visit: These unscheduled visits arise when a patient experiences a sudden illness or injury, requiring prompt medical attention.
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Telemedicine Visit: Technology bridges the distance as telemedicine visits offer remote consultations via video or phone, providing convenient and accessible care.
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Consultations: When a patient’s condition requires specialized expertise, consultations with other healthcare providers, such as specialists or subspecialists, are initiated to gather additional insights and collaborate on treatment plans.
Purpose of Clinical Encounters:
Beyond capturing patient information, clinical encounters serve a multitude of purposes:
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Establish Care Plans: Encounters provide a platform for developing and refining individualized treatment plans tailored to the patient’s unique needs and circumstances.
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Monitor Patient Progress: Through regular encounters, healthcare providers can assess the patient’s response to treatment, make necessary adjustments, and ensure optimal outcomes.
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Documentation and Communication: Encounters meticulously document patient care, facilitating seamless communication among providers and promoting a shared understanding of the patient’s health journey.
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Research and Quality Improvement: Aggregated encounter data serves as a valuable resource for research and quality improvement initiatives, contributing to the advancement of healthcare practices.
Clinical encounters are the building blocks of Epic Charting, providing a structured framework for capturing and documenting patient care. Their diversity reflects the complexities of healthcare, encompassing everything from routine check-ups to emergency situations. By understanding the purpose and types of clinical encounters, we gain a deeper appreciation for the significance of accurate and comprehensive medical records in empowering informed decision-making and enhancing patient outcomes.
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I. Entities Closest to the Topic: Epic Charting
1. Clinical Encounters
Clinical encounters are a cornerstone of patient care, providing a comprehensive record of the patient’s health status and interactions with healthcare professionals. These encounters serve as a valuable tool for tracking the patient’s journey and making informed decisions about their treatment.
Types of Clinical Encounters
- Initial Encounter: Establishes the patient’s medical history, current symptoms, and treatment plan.
- Follow-up Encounter: Monitors the patient’s progress, adjusts treatment as needed, and addresses any new concerns.
- Hospital Encounter: Documents the patient’s stay in the hospital, including procedures, medications, and discharge instructions.
- Emergency Encounter: Records urgent care provided during emergencies, including injuries, illnesses, and accidents.
Purpose in Patient Health Record
Clinical encounters provide a chronological snapshot of the patient’s health journey. They document:
- Patient demographics and medical history
- Symptoms and diagnoses
- Treatment plans and interventions
- Monitoring of patient outcomes
- Communication between healthcare professionals
Epic Charting: Unleashing the Power of Orders in Patient Care
Orders: The Lifeline of Patient Care
In the labyrinthine tapestry of healthcare, orders serve as the vital threads connecting healthcare professionals to patients, ensuring seamless and effective care delivery. Epic Charting, a widely adopted electronic health record (EHR) system, empowers clinicians with a robust order management module, revolutionizing the way orders are created, processed, and executed.
Types of Orders: Empowering Clinicians
Epic Charting offers a comprehensive suite of order types, tailored to the diverse needs of patient care.
- Medications: These orders prescribe specific drugs, dosages, and administration schedules, ensuring accurate and timely medication administration.
- Lab Tests: Orders for lab tests request specific analyses of bodily fluids or tissues, providing valuable insights into patient health and disease status.
- Diagnostic Procedures: These orders schedule diagnostic procedures, such as X-rays or biopsies, allowing for prompt and accurate diagnoses.
The Role of Orders in Patient Care: A Symphony of Coordination
Orders play a pivotal role in coordinating patient care, orchestrating a seamless flow of information and resources.
- Communication Channel: Orders serve as a clear communication channel between clinicians, ensuring that all members of the healthcare team are on the same page regarding patient care plans.
- Quality Control: By documenting orders electronically, Epic Charting minimizes errors and ensures adherence to clinical protocols, enhancing the overall quality of patient care.
- Efficiency Booster: The system’s automated order processing capabilities streamline the ordering process, freeing up clinicians to focus on patient interactions and clinical decision-making.
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Entities Closest to the Topic: Epic Charting
Orders
Orders are essential instructions that guide patient care within the Epic Charting system. They encompass a wide range of directives, including:
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Medications: Prescriptions for specific drugs, including dosage, route of administration, and frequency. These orders ensure timely and accurate medication administration for optimal therapeutic outcomes.
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Lab Tests: Requests for laboratory analyses on patient samples. Lab results provide valuable insights into a patient’s health status, aiding in diagnosis, monitoring, and treatment decisions.
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Diagnostic Procedures: Instructions for non-invasive and invasive procedures, such as imaging exams, biopsies, and endoscopies. These procedures provide visual and analytical information essential for accurate diagnoses and appropriate interventions.
II. Other Entities: Epic Charting Features
Epic Modules (Score: 10)
Epic Charting offers a comprehensive suite of modules tailored to various aspects of patient care. These modules seamlessly integrate with the core charting system, enhancing efficiency and streamlining workflows:
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Patient Portal: A secure online platform that allows patients to access their medical records, schedule appointments, and communicate with their healthcare providers.
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Inpatient Care: A module dedicated to managing the care of hospitalized patients, including admission, discharge, and ongoing treatment.
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Outpatient Clinic: A specialized module designed for outpatient settings, facilitating appointment scheduling, billing, and documentation of patient visits.
Procedure Events: Uncovering the Vital Details of Patient Interventions
Procedure events are a crucial component of Epic Charting, documenting the various interventions performed on patients. These interventions range from complex surgical procedures to routine biopsies, playing a significant role in the patient’s health record.
Understanding the Types of Procedure Events
Procedure events encompass a wide range of interventions, each with its unique purpose. Surgical procedures, for instance, are highly specialized interventions performed in an operating room and require meticulous documentation. Biopsies, on the other hand, involve the removal of tissue samples for analysis, aiding in the diagnosis and management of medical conditions.
The Importance of Accurate Documentation
Accurate documentation of procedure events is essential for several reasons. It ensures that the patient’s medical history is complete, facilitating informed decision-making by healthcare providers. Additionally, it serves as a legal record, protecting both the patient and healthcare organization in the event of any disputes.
Specific Details to Capture
When documenting procedure events, specific details should be included to provide a comprehensive picture of the intervention. These details encompass:
- Type of procedure: Specify the exact procedure performed, such as “appendectomy” or “colonoscopy.”
- Date and time: Record the precise date and time of the procedure.
- Location: Indicate where the procedure was performed, such as the operating room or the endoscopy suite.
- Provider: Identify the healthcare provider(s) who performed the procedure.
- Patient consent: Document whether the patient provided informed consent prior to the procedure.
- Complications: Note any complications that occurred during or after the procedure, along with their management.
Procedure events are an integral part of Epic Charting, providing valuable information about the interventions performed on patients. Accurate documentation of these events is essential to ensure patient safety, facilitate informed decision-making, and maintain a comprehensive medical record.
Procedure Events in Epic Charting: A Journey Through Patient Care
Procedure events form an integral part of patient care, documenting every step of surgical interventions, biopsies, and other procedures. In Epic Charting, these events are meticulously captured to provide a comprehensive record of the patient’s medical journey.
Types of Procedure Events
Epic Charting categorizes procedure events into various types, each serving a specific purpose in patient care:
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Surgical Procedures:
- Documenting the full scope of surgical interventions, including preoperative preparation, intraoperative events, and postoperative care.
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Biopsies:
- Recording the details of tissue or fluid samples collected for diagnostic purposes.
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Other Interventions:
- Encompassing procedures such as injections, insertion or removal of devices, and wound care, ensuring a complete record of all interventions performed on the patient.
Importance of Procedure Events
Procedure events are invaluable for:
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Clinical Decision-Making: Providing a clear roadmap of medical interventions, enabling healthcare providers to make informed decisions.
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Patient Safety: Ensuring patient safety by capturing details of procedures, such as anesthesia used, complications encountered, and post-procedure care plans.
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Quality Assurance: Facilitating the monitoring and improvement of healthcare practices by providing data for quality metrics.
The Role of Nursing in Procedure Events
Nursing staff plays a crucial role in accurately documenting procedure events. Their assessments and observations help create a complete picture of the patient’s condition before, during, and after the procedure. This information is essential for:
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Patient Monitoring: Tracking vital signs, pain levels, and other parameters to ensure patient well-being during and after the procedure.
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Medication Administration: Documenting the administration of medications and monitoring their effects on the patient.
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Post-Procedure Care: Providing ongoing care plans for the patient’s recovery and rehabilitation.
Procedure events in Epic Charting are essential for providing a comprehensive record of patient care, ensuring safety, and facilitating informed decision-making. By capturing every step of a patient’s medical journey, Epic Charting empowers healthcare professionals to deliver optimal healthcare.
4. Observations: A Critical Window into Patient Health
Observations, the documented readings of vital signs, pain levels, and patient assessments, form the cornerstone of patient monitoring. These crucial data points paint a clear picture of the patient’s current health status, enabling healthcare providers to make informed decisions about treatment and care.
Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, offer a snapshot of the body’s basic physiological functions. Deviations from normal values can signal potential health issues, prompting further investigation.
Pain scores are subjective assessments of the patient’s pain intensity. They help guide treatment and evaluate the effectiveness of pain management strategies. Patient assessments, conducted by nurses, provide a comprehensive overview of the patient’s physical, emotional, and cognitive state. These assessments identify changes in behavior, mood, or cognitive function, alerting providers to potential underlying conditions.
By monitoring observations regularly, healthcare providers can detect subtle changes in the patient’s condition, identify patterns, and intervene early to prevent complications. Observations are not merely numbers on a chart but invaluable tools that facilitate optimal patient care.
Observations: Monitoring Patient Health with Vital Signs
In the realm of healthcare, accurate and timely monitoring of patient health is paramount. Observations, such as vital signs, pain scores, and patient assessments, play a pivotal role in this critical process. Think of observations as the stethoscope of the electronic age, providing healthcare professionals with a snapshot of the patient’s current status.
Vital Signs: A Gateway to Understanding Health
Vital signs, including temperature, pulse, respiration, and blood pressure, offer a baseline assessment of the patient’s physiological functions. They serve as early warning signs, alerting clinicians to potential complications or changes in the patient’s condition. For instance, a rapid heart rate may indicate an infection, while a high temperature could be a sign of fever.
Pain Scores: Quantifying Suffering
Pain is a subjective experience, often difficult to convey. Pain scores provide a numerical representation of the intensity of pain, enabling clinicians to objectively assess and manage this distressing symptom. Effective pain management is crucial not only for patient comfort but also for preventing complications and improving outcomes.
Patient Assessments: Unveiling the Whole Picture
Patient assessments, conducted by nurses and other healthcare professionals, delve into the patient’s physical, emotional, and cognitive status. These assessments provide a more comprehensive understanding of the patient’s overall health and well-being. They can identify subtle changes, such as a change in mood or cognitive function, which may indicate underlying health issues.
Empowering Healthcare Professionals with Information
Observations empower healthcare professionals with the necessary information to make informed decisions about patient care. By continuously monitoring vital signs, pain scores, and patient assessments, clinicians can proactively address health concerns, prevent complications, and ensure the best possible outcomes for their patients.
Nursing Assessments: Documenting the Patient’s Holistic Well-being
In the tapestry of healthcare, nursing assessments play a crucial role in capturing the intricacies of a patient’s health. Beyond vital signs and physical observations, nurses delve into the emotional and cognitive realms to paint a comprehensive picture of an individual’s health status.
Through structured and standardized assessments, nurses gather valuable information about a patient’s physical well-being, including their overall appearance, skin integrity, nutritional status, and mobility. Their keen observations extend to pain levels, edema, and any abnormalities that may signal underlying health concerns.
But the scope of nursing assessments extends far beyond the physical. Nurses are trained observers of the emotional and cognitive state of their patients. They listen attentively to concerns, assess mood and affect, and screen for signs of depression or anxiety. Acute changes in behavior or cognitive function are meticulously documented, providing valuable insights for both diagnosis and intervention.
Nursing assessments are not mere checklists; they are dynamic narratives that tell the story of a patient’s journey. Each assessment captures a snapshot in time, providing a baseline against which changes in health status can be measured. The cumulative record of these assessments forms a longitudinal tapestry, providing a comprehensive view of the patient’s overall health and well-being.
In conclusion, nursing assessments are indispensable tools in the clinical arsenal. They enable nurses to document the physical, emotional, and cognitive aspects of a patient’s health, creating a comprehensive and individualized picture that guides care decisions and supports optimal outcomes.
The Vital Role of Nursing Assessments in Epic Charting
Nursing assessments play a crucial role in documenting the patient’s physical, emotional, and cognitive status. These assessments provide invaluable insights into the patient’s well-being, allowing healthcare providers to make informed decisions about their care.
Physical Assessments:
Epic’s charting capabilities allow nurses to thoroughly document all aspects of a patient’s physical health. This includes monitoring vital signs, such as blood pressure, heart rate, and temperature, as well as assessing the patient’s skin, respiratory, and neurological systems. These observations provide a comprehensive picture of the patient’s physical condition and help identify any potential health concerns.
Emotional Assessments:
Beyond physical health, nurses also assess the patient’s emotional well-being. They note the patient’s mood, anxiety levels, and coping mechanisms. This information is essential for understanding the patient’s overall health and providing appropriate support and counseling.
Cognitive Assessments:
For patients with cognitive impairments, such as dementia or Alzheimer’s disease, nursing assessments are especially important. Nurses evaluate the patient’s orientation, memory, and problem-solving abilities. This helps to determine the extent of the patient’s cognitive decline and develop strategies to support their cognitive function.
Documentation and Collaboration:
Epic’s electronic health record (EHR) system facilitates the documentation and sharing of nursing assessments. This ensures that all healthcare providers involved in the patient’s care have access to accurate and up-to-date information. The EHR also allows for easy collaboration between nurses and other members of the healthcare team, such as physicians, social workers, and physical therapists.
By capturing the patient’s physical, emotional, and cognitive status, nursing assessments are an essential part of Epic Charting. They provide valuable insights into the patient’s health and well-being, allowing healthcare providers to make informed decisions about their care and improve patient outcomes.
Patient Education: A Vital Component of Epic Charting
In the ever-evolving landscape of healthcare, patient education plays a pivotal role in empowering individuals to take ownership of their health. Epic Charting, a leading electronic health record (EHR) system, recognizes this importance and provides robust tools to effectively document and track patient education efforts.
Benefits of Patient Education
Thorough patient education is crucial for several reasons. It:
- Enhances patient understanding of their health conditions and treatment plans.
- Improves adherence to treatment protocols, leading to better health outcomes.
- Reduces anxiety and empowers patients to actively participate in their care.
- Facilitates communication between healthcare providers and patients.
How Epic Charting Supports Patient Education
Epic Charting incorporates dedicated features and workflows to streamline patient education documentation. These include:
- Education Library: A comprehensive repository of educational materials tailored to specific health conditions. Providers can easily search and assign relevant resources to patients.
- Patient Portal: A secure online platform where patients can access their EHR, including educational materials and reminders.
- Education Notes: A dedicated section within patient encounters where providers can document the patient’s level of understanding and the specific topics covered during education sessions.
- Goals and Interventions: Epic Charting allows providers to track and monitor patient education goals as an integral part of the care plan. This ensures that ongoing support is provided to reinforce learning.
Integrating Patient Education into Epic Charting
To effectively integrate patient education into Epic Charting, healthcare providers should:
- Utilize the Education Library: Leverage the vast library of resources to identify materials that align with patient needs.
- Incorporate Education Notes: Document all patient education encounters, including the topics covered and the patient’s understanding.
- Set Education Goals: Establish clear and measurable goals for each patient’s education plan.
- Use Patient Portal: Encourage patients to access their EHR through the Patient Portal to reinforce education and promote ongoing engagement.
By seamlessly integrating patient education into Epic Charting, healthcare providers can enhance patient understanding, improve health outcomes, and foster collaborative partnerships. The tools and features provided by Epic Charting empower providers to effectively educate patients and empower them to actively participate in their own healthcare journey.
Patient Education: An Integral Part of Electronic Health Records
When it comes to managing their health, patients need to be informed and empowered. Patient education plays a crucial role in achieving this goal. And with the advent of electronic health records (EHRs), documenting and delivering patient education has become more accessible and effective.
In an EHR, patient education is not merely a collection of handouts or a checkbox on a form. It’s an integral part of the patient’s health record that serves multiple purposes:
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Empowering Patients: When patients understand their condition, treatment plan, and self-care instructions, they become more engaged in their healthcare. They’re better able to make informed decisions and take an active role in managing their health.
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Improving Outcomes: Comprehensive patient education improves health outcomes. Patients who are well-informed about their condition are more likely to adhere to treatment plans, manage symptoms, and reduce the risk of complications.
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Enhancing Communication: EHRs facilitate seamless communication between patients and healthcare providers. Education materials can be easily shared, allowing patients to access information anytime, anywhere. This fosters open dialogue and ensures that patients have a clear understanding of their healthcare needs.
Documenting patient education in the EHR is crucial for several reasons:
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Ensuring Accuracy and Consistency: EHRs provide a standardized format for recording patient education, ensuring that the information is accurate, consistent, and easily accessible.
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Tracking Progress: Healthcare providers can track the progress of patient education and identify areas where additional support is needed. This allows for tailored interventions and improved outcomes.
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Legal Documentation: EHRs serve as legal documentation of patient education, providing evidence of the information provided and protecting healthcare providers.
By integrating patient education into EHRs, healthcare providers can elevate the patient experience, improve health outcomes, and foster an environment of informed and empowered patients.
Dive into the World of Epic Modules: Enhancing Patient Care
If you’re an avid user of Epic Charting, you’ll undoubtedly recognize the Epic Modules as the backbone of this innovative software. These specialized modules seamlessly integrate with the core charting features, empowering healthcare professionals to optimize patient care and workflow efficiency.
Imagine yourself as a physician treating a patient in the Inpatient Care module. With a few clicks, you can access the patient’s clinical encounters, orders, and observations, giving you a comprehensive view of their health status. The module’s intuitive interface allows you to quickly document assessments, manage medications, and order diagnostic tests, ensuring timely and accurate patient care.
The Patient Portal module empowers patients to actively participate in their healthcare journey. They can view their health records, schedule appointments, and communicate with their providers from the comfort of their own devices. This enhanced patient engagement fosters better health outcomes and improves overall patient satisfaction.
Beyond the realm of patient care, Epic Modules cater to specific healthcare specialties and workflows. The Outpatient Clinic module, for instance, streamlines visit management, appointment scheduling, and insurance verification for outpatient clinics. It enhances communication between providers and staff, ensuring a smooth and efficient flow of patients.
In the realm of surgical operations, the Surgical Suite module reigns supreme. It orchestrates the complexities of surgical scheduling, resource allocation, and documentation, ensuring optimal patient care throughout the perioperative period. By seamlessly integrating with other modules, it provides a cohesive view of the patient’s surgical journey.
These are just a glimpse into the vast array of Epic Modules that elevate patient care to new heights. With their tailored functionalities, seamless integration, and user-friendly interfaces, these modules empower healthcare professionals to deliver exceptional care, improve patient engagement, and optimize their workflows. Embracing the power of Epic Modules can revolutionize your healthcare practice, propelling you to the forefront of innovation and patient-centric care.
Epic Charting: A Comprehensive Guide to Entities and Features
Entities Closest to the Topic
Clinical Encounters
Every patient interaction is captured as a clinical encounter in the EHR, providing a chronological record of their health journey. These encounters include office visits, telehealth appointments, emergency room visits, and more.
Orders
Physicians and other healthcare providers issue orders to guide patient care. These may include medication prescriptions, lab tests, diagnostic procedures, and other interventions. Orders help ensure that patients receive the appropriate care promptly.
Procedure Events
Epic Charting meticulously documents all procedures performed on patients, from routine check-ups to complex surgeries. This information is vital for tracking patient progress and outcomes.
Observations
Vital signs, pain scores, and patient assessments are essential for monitoring patient health and identifying changes that require intervention. These observations are diligently recorded in Epic Charting.
Nursing Assessments
Nurses play a crucial role in assessing patients’ physical, emotional, and cognitive status. Their assessments provide a holistic view of the patient’s condition and contribute to comprehensive care plans.
Patient Education
Epic Charting empowers patients to take an active role in their health by providing educational materials and documenting discussions about treatments and care plans. This feature fosters patient understanding and promotes self-management.
Other Entities: Epic Charting Features
Epic Modules (Score: 10)
Epic offers a comprehensive suite of modules designed to streamline specific aspects of patient care. These include:
- Patient Portal: A secure online platform that allows patients to view medical records, message providers, and manage appointments.
- Inpatient Care: A comprehensive module for managing all aspects of inpatient care, including admission, discharge, and medication administration.
- Outpatient Clinic: A specialized module tailored for outpatient encounters, offering features such as appointment scheduling, documentation, and billing.
