Clinical Documentation

MDCare EMR renders 5 ways of effective clinical documentation; use any method that suits you the best. MDCare is developed and equipped with an advanced use of technology and medical resources by an efficient team of physicians and senior software developers with years of healthcare domain expertise. The five different ways are described below:

  • Structured templating.
  • Free text entry.
  • Speech recognition.
  • Tablet PC Hand writing recognition.
  • Voice dictation/transcription

Structured Templating:

MDCare EMR renders multiple specialty-specific electronic charting templates that have already been created by an efficient team of physicians and are usable anytime on MDCare EMR platform. Several industry experts indicate that templates and their underlying integrated structured language will standardize medical documentation and promote interoperability of systems and will also allow for the utilization of data for clinical research and for the good of medicine as a whole.

MDCare EMR facilitates multiple medical specialties by providing a data-set that can be customized according to the physician-specific, specialty-specific documentation workflow with an enhanced feature of customizing the data set themselves that best suits the provider’s style and determine the documentation work-flow that best conforms to their own thought process.

MDCare EMR, an innovative product of Vision Infonet Inc., can also be tailor-made to replicate the clients’ existing workflow and documentation similar to their existing templates/forms. MDCare EMR offers user-friendly custom point-and-click templates for client-specific unique documentation needs.  Vision Infonet assists the clients through the maze and provides customizable solutions with proven technology for clients practice.

Free Text Entry

MDCare EMR facilitates flexible templates construction and designs with strategically placed “comment boxes” where users can more distinctly clarify findings. Users who prefer free text entry are provided with large text fields and are permitted throughout the system. MDCare EMR provides an option of using a combination of free text, macros, medical dictionary, and templates for effective clinical documentation.

Speech Recognition

Vision Infonet primarily focuses on improvements in efficiency, clinical workflow, and quality of care. Vision Infonet understands speech recognition interface is an essential adjunct in effective, user-friendly, and easier clinical documentation. MDCare EMR has integrated speech recognition tools with advanced usage of technology. We bring to you an authentic, reliable, and HIPAA compliant stable Electronic Medical Record solution with proven technology to meet the specific requirements of each specialty.

Tablet PC Hand writing recognition

MDCare EMR/PMS platform allows for embedded and direct handwriting, as well as handwriting recognition on a Tablet PC. MDCare EMR is one of the first of its kind designed and built specifically to have tablet PC Hand writing recognition enabled services. Tablet PC provides an additional way to enter data into the EMR fields through its unique handwriting recognition capability

Voice dictation/transcription

MDCare EMR supports Clinical Document Architecture (CDA) for Clinical Document Types (CDT) sometimes described as CDA4CDT (standard for Integrating Narrative Notes and the EHR).  These new protocols empower transcription providers to deliver structured documents including both printable and importable forms of data. Eventually, by acceptance of these data formats the power of interfacing will be amplified and the effort is minimized. With MDCare EMR clients can document their patient’s charts with best use of technology, reduced time, and effort. 

Vision Infonet understands, with the growing demand for higher quality and better patient care, physicians are looking for efficient user-friendly documentation alternatives and practice management solutions.  MDCare EMR/PMS is a one-stop solution for all your clinical documentation needs and comprehensive Practice Management Solutions with all advanced integrated features such as scheduling, clinical documentation, patient education forms, HL7 interface, integrated billing module, efficient AR module, documentation management, denial management, HIPAA, e-prescription with SureScripts interface, and multispecialty support.

As Per the traditional way, the Provider Spends About 15 Minutes and 5 Minutes additionally to complete documentation. With our predefined test drop down and auto documentation the physician spends only 2-3 minutes for each patient.

The physician enters data into a computer, with the assistance of templates that incorporate most of the standard elements of his practice. An allergist, for example, will have a template that requires only one or two clicks of a mouse (or similar input mechanism) to record an allergy to dust mites or mold.

Shows all the previous labs, prescriptions with previous history.

  • Decision making assistance and Drug interaction warnings during documentation.
  • Provides the ability to electronically document patient encounters. The application enables users to document a patient's visit, automating the tasks associated with charting patient exams and assessments, resulting in a secure electronic medical record.
  • Document your encounters faster with customizable templates and forms that adapt to your preferences, specialty, and unique work flows.
  • Eliminate paper by consolidating consult letters, patient files, Insurance IDs, consent forms etc. with built-in imaging functionality.
  • Template-driven documentation;


  • Patient Demographics
  • Problems and Complaints
  • Family History
  • Social History
  • Past Medical History
  • Surgical History
  • Vital Signs
  • Chronic Conditions
  • Allergies
  • HPI (History of Present Illness)
  • Review of Systems
  • Physical Examination
  • Final Diagnosis
  • Flow Sheets
  • Phone Encounters
  • Immunizations
  • Current medications
  • Assessment and Plans
  • Procedures.
  • Growth Charts, BMI Charts etc.
  • Progress Notes.
  • Medication / Prescription Module.
  • EM Coder
  • Customizable Medical Office Forms.
  • Customizable Patient Educational Materials

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