The BestNotes Profile: Comprehensive, Compliant, and Efficient Clinical Documentation
- Ready-to-use clinical documentation
- Audit & accreditation compliant
- Pre-programmed for intelligent movement of data
- Automatic updates
BestNotes features a pre-built, comprehensive documentation system known as the "Profile." This system is designed to streamline the entire client journey, from admission through discharge. It encompasses all critical clinical documentation, including assessments, treatment plans, progress notes, and group notes, seamlessly integrated by the BestNotes content management team.
The Profile is engineered for continuous audit readiness, ensuring adherence to Joint Commission, CARF, and national standards. Automatic updates maintain ongoing compliance with evolving regulations. To maximize efficiency, data flows between documents, eliminating redundant data entry.
Clinical Profile content
Assessments & Treatment Planning:
Online Patient Application and Pre-Screen
Pre-Screen/Intake
Comprehensive Diagnostic Assessment (Multi-Dimensional Format)
History and Physical Exam
Psychiatric Evaluation
Medical/Nursing Assessment
Case Management & PRP
Including Initial Treatment Plan & Treatment Plan Review
Master Treatment Plan
Discharge Summary
Delivery of care:
Progress Notes: Clinical, Psychiatric, Medical, CBRS, Peer Support, Case Management
Medical Chart Note
Utilization Review
Collaboration
Missed Services
Unscheduled Encounter
Group Therapy
Incident Report
Treatment Team