Wellsoft - The Heart of Your Emergency Department
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Product Overview

Clinical Documentation

Wellsoft EDIS allows for fast and complete clinical documentation through the use of dynamic complaint specific templates. Pop-up menus are customized for each hospital to enable quick entry of information with the ability to free text at any given point.  Wellsoft EDIS can bring forward patient information from previous visits to populate fields in the current record. Charts from previous visits are immediately available to support patient care decisions.  Documentation for ancillary services is also available for disciplines such as Respiratory Therapy, Social Services, Case Managers and Psychiatry. Copies of the chart can be sent electronically to any HL7-compliant system such as a CDR or HIS.

Triage

Custom-configured screens for triage and assessment can be as brief or complete as the department wishes. All triage data such as patient information, presenting complaint, acuity, vital signs, and initial assessment can be captured. A unique triage impression feature provides an extensive list of clinical elements to better communicate patient presenting illness and expected course of treatment.

Nursing Documentation

Easy-to-use templates facilitate complete nursing documentation. Pop-up menus provide fast documentation of clinical treatments, clinical assessments, procedures and interventions. Templates are easily customized to support the hospital’s standard of care and requirements such as Fall Risk Assessment are included. Access to all POC tests is streamlined in a single location in the patient record and provides one source for all POC information.

  • Facility Charge Capture

Faster and more efficient billing is achieved using automatic charge capture and coding.  Wellsoft EDIS automatically captures charges, eliminating lost charges from manual data entry and check boxes on a charge sheet.  Charge capture routines are based on nursing and physician documentation and order entry.  All codes (CPT, HCPCS, APC and ICD-9) will be populated as soon as a diagnosis is determined, a procedure is documented or an order is placed.  The chargeable items and codes can be displayed, printed or sent via HL7 interface to a billing system.  This process enables the hospital to generate a more accurate facility level bill, supported by the medical record.

Physician Documentation

Intuitive complaint-driven templates prompt the physician for all required documentation elements (HPI, ROS, PMH, PSH, Physical Exams, Procedures, Progress Notes, Decision Making) using pop-up menus and custom pick lists.  Free text can be added at any time. Any method of data input including voice recognition or handwriting recognition tablets can be used.

  • Professional E&M Level Scoring

Faster and more efficient billing is achieved using our automatic professional evaluation and management scoring feature. Wellsoft EDIS will automatically determine the E&M level of service for a particular patient visit based on physician documentation, procedures, orders, results and final diagnosis. Physicians will have the option of viewing their current E&M level at anytime during a patient’s visit. This summary view will include a breakdown of all the elements (HPI, PFSH, ROS, Physical Exam, Decision Making) contributing to the E&M level of service.

  • Professional Charge Capture

Faster and more efficient billing is achieved using our automatic professional charge capture and coding feature. Wellsoft EDIS will automatically determine the E&M level of service for a particular patient visit based on physician documentation, procedures, orders, results and final diagnosis. Physicians will have the option of viewing their current E&M level at anytime during a patient’s visit. This summary view will include a breakdown of all the elements (HPI, PFSH, ROS, Physical Exam, Decision Making) contributing to the E&M level of service. All billing codes (CPT, HCPCS, APC and ICD-9) will also be populated as soon as a diagnosis is determined, a procedure is documented or an order is placed. All chargeable items and codes can be displayed, printed or sent via HL7 interface to a billing system. This process enables the hospital to generate a more consistent and objective professional level bill, supported by the medical record.

Ancillary Services Documentation

Versatile multi-discipline templates are provided for ancillary services documentation.  Services such as Respiratory Therapy, Social Work, Chaplain, Case Manager and Psychiatric can all be easily documented. Templates are customized to meet any hospital specific documentation need.

Special Needs Patient Care Plans

Store a longitudinal record of patient specific protocols for special patients, typically those with chronic issues, such as sickle cell anemia, migraines, and pain management.  Links notify the user upon registration of an identified special patient.  Wellsoft maintains individualized “care plans” for these patients enabling physicians to maintain continuity of care by being informed of the patients’ history of treatment and any other pertinent information.

Intake & Output Table/Calculator

Wellsoft's fluid intake and output table allows clinicians to electronically document patient fluid (e.g., blood, urine) intake and output data supported by automatic total fluid balance calculations.

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