Documentation with ONCOCHART
Proper documentation is perhaps the most difficult and time-consuming part of the treatment cycle for centers to get their hands around. Not only does documentation take an inordinate amount of physicians’ time, it also has become a prime target when charts are audited.
ONCOCHART solves these problems by assisting the physician’s documentation of procedures. There are literally thousands of pre-defined questions and answers programmed into ONCOCHART that let the physician shape the documentation as required. If one of the pre-defined answers is not appropriate, the physician can either enter another of his/her choosing or dictate directly into the microphone attached to their computer via a voice dictation software such a Dragon Naturally Speaking or other available voice dictation solutions.
Many of the documents will have answers that will not vary a great deal for a specific diagnosis. ONCOCHART allows the creation of “template” repetitive answers, where appropriate, to save the physician valuable clinical time.
Portions of the documentation can be completed by others in the center (PA’s, Nurses, Therapists, Dosimetrists, etc.), but all documentation requires the final approval by a physician. Once that final approval is given, that procedure is sent to billing and the documentation is considered “recorded”.
Completed documentation can either be retained electronically (and viewable through the patient’s Electronic Medical Record (EMR)) or printed for inclusion in the patient’s chart. All documentation is HIPAA compliant and can be electronically copied (via secure email or FAX) to referring physicians in Narrative or Brief format. E&M documentation can also be sent in Physician Letter format.
ONCOCHART Documented Procedures
- H & P
- ONS Based Nursing Documentation
- Treatment Planning (prescription)
- Progress Notes
- End of Treatment Summary
- Conventional Simulation
- 3-D Dosimetry
- Isodose Plan
- Treatment Devices
- Brachy Therapy Procedures
- Gamma Knife and SRS
- Physics Reports