Uniform Data Systemfor Medical Rehabilitation

270 Northpointe Parkway, Suite 300Amherst, New York 14228tel: 716-817-7800fax: 716-568-0037www.udsmr.org

The UDS-PRO Doc™ System is a clinical documentation system for inpatient rehabilitation. The software is a smart client application that allows users to access the system from any Internet-enabled computer. Unlike many of the systems available today, this system was designed by rehabilitation clinicians for rehabilitation clinicians.

The system combines the two requirements of documenting care and rating the FIM® items for the IRF-PAI into one task, helping clinicians generate accurate ratings. The UDS-PRO Doc™ System is designed to interface with other hospital information systems to improve efficiencies and eliminate errors associated with “double data entry,” and it is capable of warehousing as much clinical data as the facility desires. Its design also allows it to interface with electronic health record (EHR) and electronic medical record (EMR) systems that may already be in use at your facility.

Product BenefitsThe UDS-PRO Doc™ System’s clinical documents are integrated with, and support, the IRF‑PAI. This integration provides better compliance and makes your records more likely to sustain appeals denials.

The software’s user‑friendly interface supports interdisciplinary documentation, making it easier for your nurses, therapists, and physicians to work together.

You’ll need less FTE time to accomplish required documentation tasks thanks to the UDS-PRO Doc™ System’s many time‑saving features:

• Copy forward

• SmartFIM™ module

• Auto-population of IRF-PAI ratings

• Case management and case review features

The twin tasks of documenting the case and rating the IRF‑PAI items are combined into one, saving time and improving accuracy and timeliness.

The SmartFIM™ module uses rating guidelines to recommend appropriate FIM® ratings.

The software’s optional HL7® interfacing improves efficiency and reduces duplication of data entry and errors.

And the system allows you to scan external documents as attachments to the case record.

UDS-PRO Doc™ System

© 2009, 2010 Uniform Data System for Medical Rehabilitation. CareTrend PRO, FIM, SmartFIM, UDS-PRO, UDS-PRO Doc, UDSPRO Central, and the UDSmr logo are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. HL7 is a registered trademark of Health Level Seven International.

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Uniform Data Systemfor Medical Rehabilitation

270 Northpointe Parkway, Suite 300Amherst, New York 14228tel: 716-817-7800fax: 716-568-0037www.udsmr.org

UDS-PRO Doc™ ModulesFacesheet: Displays patient data from the hospital information system and the IRF-PAI.

Clinical Summary: Provides a customized display of pertinent patient information from multiple sources of interdisciplinary documentation.

Plan of Care: Pulls interventions, problems, focus areas, and goals together for easy access and tracking.

Clinical Documents: These comprehensive and customizable documentation templates focus on supporting medical necessity, assisting in accurate FIM® rating assignment, and demonstrating interdisciplinary team communication.

SmartFIM™ Module: Captures all FIM® documentation from multiple clinical documents and stores it in one location. The SmartFIM™ module uses rating guidelines to recommend the appropriate FIM® ratings.

CareTrend PRO™ Module: Provides customizable patient reports on items like therapy treatment time logs, FIM® documentation, pain ratings and interventions, and completed interdisciplinary education for user-defined time frames.

Additional Patient Info: Allows the user to enter and view additional information such as facesheet data, diagnoses, allergies, required consent forms, related acute medical record documentation, and the patient’s rehabilitation visit history, and to add other attachments.

IRF-PAI View: Allows the user to view the entire IRF-PAI from the UDSPRO Central™ software.

User Setup: Allows administrators to set up UDS-PRO Doc™ user accounts with a customizable and unique set of permissions for each user.

Audit Log: Tracks changes made to the entire documentation system, including user access, data changes, module access, and more.

Online Help: Provides complete and comprehensive online documentation for the entire software system. Documentation is accessible and specific to each module and screen, providing quick and easy access to the specific section of the Help system the user needs.

UDS-PRO Doc™ System