Clinical Documentation Support

Every medical (or digital health) encounter has a beginning, middle, and end. Each encounter begins with a chief complaint (reason for visit). Each encounter has a middle where the various workflow processes occur. Each encounter typically ends with some type of process outcome, be it care advice, a diagnosis (cause), a disposition, recommended treatment, or other health information.

Health Navigator gives you building blocks that digitally replicate and support the information exchange that happens in a medical encounter; for the beginning, middle, and end.

Health Navigator’s Clinical Documentation Support (CDS) engine supports the middle of the medical encounter by delivering the right questions to ask a patient for the following digital health encounters:

  1. Initial Patient Intake. Take a clinical history from an asymptomatic patient for use in future encounters.
  2. Emergency Screening and Prioritization. Ask a few questions, specific to the patient’s main complaint, to determine if this is an emergency. Redirect patients with positive responses to other sources of care (such as 911), or prioritize who should the telehealth provider speak with next.
  3. Consumer-facing Symptom Checker or Health Bot. Ask the right questions to and pass the positive and negative responses into the Health Navigator Triage or Diagnosis Engine.
  4. CarePaths. When a patient self identifies a diagnosis at the start of an encounter, appropriate questions related to the condition are presented. This CarePath will help determine if the patient has that condition or if it could be something else.
  5. Consumer-facing eVisit Form. Ask the right questions to pass along to the patient’s primary care provider or telemedicine provider.
  6. Provider-facing Documentation Checklist. Create a documentation checklist.

Clinical Documentation Support - Tell Us More in English and Spanish

Here is a sample user interface of questions that would be presented to the patient during the CarePath.