In a scenario of accelerated digital transformation in healthcare, clinics and medical centers that serve different specialties need to deal with a growing challenge: integrating professionals, processes, and information into an efficient workflow. Electronic health records (EHR) emerge as a fundamental piece in this context, but their effectiveness is directly related to the ability to customize and adapt to the reality of each clinic.
Standardized medical records can limit productivity and compromise the quality of care. On the other hand, a customizable electronic health record allows for real gains in security, team integration, and clinical decision-making. In this article, we will discuss how a customizable EHR can improve management in multidisciplinary clinics.
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The Challenge of Multi-professionalism in Clinical Practice
Multidisciplinary clinics bring together different specialists, such as physicians, physiotherapists, psychologists, speech therapists, and occupational therapists. The diversity of approaches requires a system capable of recording clinical information with rich detail, respecting the uniqueness of each area without losing the comprehensive view of the patient.
Without a medical record that adapts to this reality, bottlenecks emerge such as:
- Difficulty accessing information by other professionals
- Confusing or incomplete records
- Time wasted on manual processes and rework
- Failures in interdisciplinary communication
These problems directly affect the patient experience, treatment effectiveness, and team productivity.
Benefits of Customizable Electronic Health Records
By adopting a system with customizable electronic health records, the clinic gains access to a resource adapted to the real needs of healthcare practice. Among the main benefits are:
1. Form Templates Adapted by Specialty
The system allows for the creation of medical histories, progress notes, and clinical protocols specific to each type of care, such as:
- Orthopedic scales (IKDC, AOFAS)
- Behavioral assessment (ABA)
- Physical therapy forms
- Questionnaires for psychology and nutrition
With this, professionals have agility and assertiveness in record-keeping, and the data becomes more structured and comparable over time.
2. Complete History with Visual Evolution
Throughout various consultations and specialties, it is possible to follow the patient's timeline, with filters by professional, type of care, or healthcare area. This facilitates a global understanding of the case.
3. Sharing Among Team Professionals
With configurable permissions, team members can access records from other professionals, maintaining continuity of care and avoiding duplication of information. In ABA clinics, for example, this feature is essential for joint monitoring of the therapeutic plan.
4. Inclusion of Various Files
The customizable electronic health record allows for the attachment of exams, reports, audio, images, and even videos, enriching the patient's history and ensuring more robust and secure documentation.
Practical Application Cases: When Customization of Medical Records Transforms Care
The adoption of a customizable electronic health record is not just a technological choice but a strategic decision with a direct impact on the quality of care, team productivity, and patient experience. This type of resource is especially valuable in clinics with complex routines and multiprofessional teams, where care needs to be documented in an integrated, accessible, and detailed manner. Below, we highlight three practical contexts in which the customization of medical records brings measurable gains:
Multidisciplinary Clinic: Integrated Vision with Professional Autonomy
In clinics with different specialties operating simultaneously—such as physical therapy, psychology, nutrition, speech therapy, and medicine—the ability to configure specific forms for each area is essential. A nutritionist, for example, can rely on forms focused on food intake and BMI, while the physiotherapist uses records of mobility, pain, and functional performance. All this data is centralized in the patient's history, with filters by professional, type of care, or period.
This customized structure allows each specialist to maintain their clinical autonomy without compromising the integrated view of the case. Additionally, structured progress reports facilitate team meetings, adjustments to the therapeutic plan, and even patient engagement with their own health journey.
Rehabilitation Clinic: Precise and Documented Control of Progress
In motor, neurological, or cardiorespiratory rehabilitation services, patient progress depends on small improvements over multiple sessions. In these cases, the electronic health record needs to allow structured documentation of each encounter, with specific fields such as: session objective, techniques applied, immediate patient response, and relevant observations.
A good example of practice is the use of customized checklists for each type of pathology or treatment phase, in addition to the automatic generation of progress graphs by indicators. This helps both in assessing therapeutic effectiveness and in providing technical justification for insurance companies and audits. Systems like Ninsaúde Clinic offer this level of detail, with configurable models that adapt to the specialty and protocol adopted by the clinic.
ABA Clinic: Technical Support for Behavioral Analysis
Clinics that work with Applied Behavior Analysis (ABA) deal with patients who demand continuous interventions, often performed by a team composed of analysts, therapists, and companions. The complexity of the data—such as frequency of behaviors, presented stimuli, and types of reinforcement—requires a medical record that goes beyond descriptive recording.
With a customized medical record model for ABA, the team can record each intervention with time marking, apply specific protocols such as VB-MAPP or ABLLS-R, attach session videos, and generate standardized performance reports. Another essential point is sharing part of these records with caregivers or legal guardians, which promotes greater family involvement and continuity of strategies outside the clinical environment.
In Ninsaúde Clinic, for example, it is possible to configure multiple access profiles and generate automatic summaries with email delivery, ensuring agility and security in communication with those responsible.
Recommended Features for More Efficient Management
For the electronic health record to be truly effective in multidisciplinary environments, it is essential that the system has:
- Customizable forms with required fields option
- Access profiles segmented by function/profession
- Visual history and advanced filters
- Integration with scheduling, financial, and CRM systems to centralize management
- Compliance with data protection regulations and data encryption
Ninsaúde Clinic, for example, offers all these functionalities, allowing clinics of various sizes to adapt the medical record to their practice, including pre-configured form templates, analysis of progress by specialty, and customized access permissions.
How to Implement Successfully
Migration to a customizable electronic health record should be accompanied by a well-defined strategy. Some recommendations for an efficient process:
- Map current clinical workflows: identify the specific needs of each team.
- Define form templates and essential fields: involve professionals in the construction.
- Train the team: adequate training avoids resistance and operational errors.
- Implement in stages: start with a pilot specialty or sector.
- Monitor usage and adoption indicators: use data to optimize configuration.
The support of a specialized team, such as that offered in the Ninsaúde Clinic onboarding, makes a difference in the customization and integration of functionalities into the clinic's day-to-day operations.
The Impact on Patient Experience and Clinic Results
When well-utilized, the customizable electronic health record positively impacts the entire patient journey:
- Reduces waiting and service time
- Facilitates access to information by all involved in care
- Ensures greater security in decision-making
- Improves the perception of service quality
From a management perspective, structured data helps in administrative decision-making, performance reporting, and defining improvement strategies.
Customization as a Growth Strategy
In times of high competition and increasingly demanding patients, investing in an electronic health record that respects the individuality of clinical practice is a strategic decision. More than digitizing, it's about integrating, customizing, and optimizing.
Systems like Ninsaúde Clinic show how technology can be adapted to the clinic, not the other way around. This allows healthcare institutions to provide care with higher quality, productivity, and safety. A well-configured electronic health record is not just a tool; it's part of the strategy for growth and enhancing the patient experience.
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