Clinical Operations

CIM Systems offers a variety of ChartEvolve modules to help your organization achieve a level of operational efficiency.

  • Order Entry / Results Reporting Module (CPOE)
  • Electronic Prescribing Module
  • Drug Dispensing Module
  • Drug Alert System
  • Kennedy Psychiatric Treatment Planning System Module
  • Testing Module (Psychiatric, Psychometric, Inventory)
  • Individual Education Planning Module
  • Electron Claims Module
Clinical Operations refers to how our standards of training, standards of practice and standards of care provides structure to the evaluation and treatment of our patients.

When operationalized into an Electronic Health Record System, these standards are best expressed in what is known as a structured clinical interview technique.

Fortunately, a structured clinical interview technique is strongly supported by Federal Law and the Documentation Guidelines of the Centers for Medicare and Medicaid. This is the backbone of the methodology by which all clinicians in the United States are reimbursed for the clinical care they deliver as a means to earn a living as licensed clinicians.

These rules are not peripheral as many clinicians would like to hope. They are central to understanding how to turn your practice into a successful clinical and commercial entity.

The Clinical Interview is broken down into distinct invariant sections:

Documentation of History
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family and/or Social History (PFSH)

Documentation of Psychiatric Examination

Documentation of the Complexity of Medical Decision Making
Number of Diagnoses or Management Options
Amount and/or Complexity of Data to Be Reviewed
Risk of Significant Complications, Morbidity, and/or Mortality

Documentation Dominated by Counseling or Coordination of Care

The rules for Psychiatry, which serve all the disciplines in Behavioral Health, provide an exceptionally well structured process for the examination of the mental health patient.