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Health Records

GoldCare’s Health Records Manager provides you with a multi-disciplinary approach to fully document every aspect of your residents/clients’ health care. Standard templates, codes and libraries, along with automatic time stamping and version tracking, support professional standards for complete and accurate clinical documentation. All data is protected to ensure record security and resident/client confidentiality.

• Streamlined Data Entry: Improve the accuracy and efficiency of data entry using an easy-to-navigate interface, text shortcuts, libraries, searchable health records database and more. Full integration with other GoldCare applications such as Assessment Information Manager (AIM) and Admission/Transfer/Discharge (ADT) allow you to access care plans and ADT histories directly from Health Records.

• Resident/Client Profile: Manage resident/client information with the Resident/Client Profile, which uses individual “at a glance” windows to segment multiple fields of data for quick access: dietary profile, allergies, personal contacts, and more. For further flexibility, a more centralized and consolidated view of resident/client information is available through the Resident/Client Dashboards and Workspaces.

• Progress Notes: Define the types of progress notes to correspond with your site’s specific needs, or use one of the many standard progress note templates available in GoldCare. Progress notes are multi-disciplinary, which enables the staff of a particular discipline to readily access and update their own notes, rather than search through all the progress notes on file.

• Vital Signs: Enter the vital signs for different residents/clients at once with GoldCare’s convenient "batch entry" method. Each entry is saved as part of the resident/client’s health record, and can be accessed from that record in addition to other documentation. Vital signs data can also be displayed as a graph for comparison and tracking purposes.

• Data Security: Maintain the integrity and confidentiality of resident/client data with various GoldCare security measures including user-defined permissions, electronic signatures, automated date and time stamping, and more. Version tracking and audit logs give you a clear record of file activity and data changes.

• Medical Diagnosis: Diagnoses can be entered using a variety of standardized coding systems such as ICD-9, ICD-10 and READ. Diagnoses can be customized with keywords and shortcuts, or using a unique site-defined diagnosis system, making it easier for the clinician to find the correct code.