Maintaining impeccable clinical documentation and resident records in an industry with little time to spare is no mean feat. With ever-changing guidelines, strict deadlines, and compliance reporting to factor in, carers can lose substantial time to administrative tasks which could be used to deliver quality care to residents.
Discover everything you need to know about Clinical Documentation Systems in aged care including the benefits and how it can help support your aged care home.
What is a Clinical Documentation System?
A clinical documentation system creates uniform files of residents' care records and their clinical records. Using standardised data elements in resident care adds consistency and context to resident information.
Clinical documentation can include charted and reported medical documentation during standard care visits, notes on resident safety, background clinical documentation, and upholds the integrity of electronic health records and other forms of clinical records.
Clinical documentation improvement
Clinical documentation has evolved from paper-based practices requiring a vast amount of space and organisation, to electronic health record systems in the majority of aged care facilities.
Clinical documentation improvement is the process by which health care record processes and documentation is improved to create a more robust system to enhance and optimise data quality and resident care.
Why Care Manager Software should be important to you
Care management software is a form of clinical documentation software which can automate a variety of chores for you. It enables you and your team to devote more time to resident care rather than document management and provides opportunities for resident care improvements.
Clinical documentation software can assist in managing the complete healthcare service cycle from the perspective of your residents. It can help administration staff monitor and balance resident care through up-to-date clinical documentation, guaranteeing that each resident receives the highest possible care. It automates converting time-consuming paperwork into a digital system that handles everything and allows you to spend less time on paperwork and more time on caring for residents which helps increase the quality of your care service.
Clinical documentation software also offers an opportunity for clinical documentation improvement, optimisation of resident safety, and a more efficient standardisation of electronic health records.
10 benefits of using a Clinical Documentation System in aged care facilities
Clinical documentation systems can significantly improve resident care, reduce risk, and create more efficient processes. Here are 10 benefits of using a clinical digital documentation system within your aged care home.
Instant access to information
Gain instant access to resident records and related data with clinical documentation software to save time and create more efficient processes.
Live real-time evidence of care
As soon as a member of your team enters new information, the electronic health record is updated everywhere else. This ensures accurate and up-to-date information on every resident at all times.
Supports continuous improvement
Everyone who needs access to your residents' electronic health records can access them securely at any time and offer visual and text-based clinical documentation to analyse healthcare trends and measure data critical to your core KPIs.
Removes duplication of care information
Improve efficiency and accuracy using clinical documentation software. Remove the likelihood of duplication of care information using software which updates instantly.
Plan person-centred care routines
Create care routines based around individual residents, using clinical documentation software to monitor and improve the experience your residents receive.
Empower your whole team to succeed
Give your team the tools they need by giving them access to up-to-date information, accessible wherever they are whenever they need it. Availability of information across the entire team helps them offer joined-up care and improved communication.
Monitor care effectively
Improve effectiveness with real-time monitoring, visualisation tools, and customisation options to create an effective care plan based on the latest information available. Using clinical documentation software could save your carers over an hour a day, time which can be redirected from administrative tasks to improving levels of care.
Provide a safe and responsive service
Having accurate, up-to-date information is critical to providing safe healthcare services to your residents. Clinical documentation software offers an easy-to-use record taking platform, helping to reduce the risk of errors, duplication, and miscommunication.
Share care information with people involved
Aged care home facilities can use clinical documentation software to securely store and access resident data which is always available to all healthcare professionals who need it.
Analysis of care quality
Care quality standards can be analysed quickly and easily using data and visualisation tools provided within the clinical documentation software, to help identify patterns, and get an in-depth understanding of care quality within your aged care home.
Getting started with a Clinical Documentation System – Aged care management made simple
PCS’s Clinical Care System is aimed specifically at accommodation-based aged care settings which include residential homes, day care services, mental health and learning disability services, supported living and extra care. People work in aged care because they love caring for people, but paper-based admin systems add unnecessary stress to their jobs. The main aim of aged care is to improve the quality of life for people who are cared for. We believe this should extend to the people providing care as well!
Our multiple award-winning Clinical Care System is recognised by the aged care sector as the most easy-to-use, efficient and clinically proven care documentation system. Over 3,500 care homes already use a Clinical Care System and manage the digital care records of over 100,000 residents globally. Currently, about 6 million care records are added via the Care Delivery App every single day globally.
