Clinical Record Keeping

OMS Software provides your practice/agency with easy to use completely electronic clinical record keeping. All forms/documents produced by others outside your practice/agency is easily digitized and integrated into the OMS clinical record of applicable patient files.

OMS software is user friendly.  Even your least computer knowledgeable clinician or staff member will marvel at how fast they learn to use OMS software. Once clinicians/staff begin using and learning OMS 1.0 or 2.0, they will no longer want to produce clinical records any other way.  Patient rights to privacy is also enhanced.  Access is reduced to only those clinicians working the case.  Files are securely locked away with password security protection.

The clinical record keeping feature includes the following data entry forms:

Note: we can customize the software to meet any specific needs you may have.  If you don't see a form that you need let us know.

- Phone intake form ( initial contact )

- Release of Information

- Initial Screening

- Nutritional Screen

- Patient History

- Treatment Plan

- Progress (Treatment) Notes

- Patient History Updates

- Termination/Transfer Summary

- Digitizing Documents for Insertion

OMS Software was designed by the President of a Mental Health Agency comprised of Psychologists, Therapists, Case managers, Psych Nurses and Behavioral Specialists.  OMS 1.0 and 2.0 are fully integrated modules which provide the clinician, case manager, residential services worker, nurse, or physician with a state-of the-art tool which focuses on the client’s treatment goals and objectives as well as office management solutions.

Progress notes are available for individual, group or case management sessions. Group session notes can be created using a general note for all group members and then individualized for each group member. Progress notes are linked to specific goals and objectives as required by JCAHO, COA, and CARF guidelines

Assessments are completed and documented using a combination of check boxes and narratives. Special assessments for suicide lethality, homicide lethality, potential for violence, life skills, and substance abuse are linked to the main assessment and are incorporated as necessary or required. A comprehensive mental status evaluation is included as a standard tool for the clinician to assess the overall level of functioning of the client. Assessments do not need to be exported to word processors for editing and printing. They can be edited on the spot.

The Clinical Records feature provides an efficient system to document the treatment process from the point of initial contact through the intake assessment, treatment plan development including goals, objectives and interventions, progress notes, status reviews and termination of treatment. Utilizing the Person Centered Planning process, staff can document who participated in the care conference and what the strengths and needs of the consumer are, which ultimately results in the development of goals, objectives, and interventions.