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Our Clinical Record’s Unique Design

Each version of DecisionBase includes anywhere from 18 to 50 procedure specific forms.  They are laid out step-by-step following the work flow of each procedure.  The user merely selects terms in each step that document what was observed or provided.  It’s like making selections from a restaurant menu.  Going through a procedure’s form is also similar to working with a step-by-step checklist.

After completing the selections, DecisionBase compiles them into a Word document without any typing.  The  format of these chart notes is similar to an outline, thus making it easier and faster to review.

This concept of using a clinical record as a checklist can reduce errors or omissions, thereby elevating the quality of care provided to the patient.  The checklist design can result in more accurate and detailed chart notes and may assist in guiding the clinician through the various steps in an examination or treatment procedure to make sure nothing is forgotten or left out.

As new procedures are developed and used to examine or treat patients, DecisionBase will develop new procedure specific forms and publish them with periodic updates to our software.  Much of our new development comes from requests from the users of the DecisionBase clinical record system.  We have learned that listening to feedback from our users is important to improving our software.

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