DecisionDoc EHR integrates proprietary algorithms, intelligent automation, diagnostics, and revenue management into a single HIPAA-compliant ecosystem.
Every module is engineered to enhance clinical accuracy, reduce administrative burden, and support compliance at every stage of the healthcare process.
Each service below represents a core function within the DecisionDoc environment—seamlessly interconnected through secure FHIR-based data exchange and protected by enterprise-grade security protocols.
Adheres to HIPAA documentation and patient privacy standards
CPT/ICD mappings align with CMS coding requirements
Audit trails meet federal and payer-level recordkeeping expectations
The Encounter Form is the foundation of DecisionDoc’s workflow.
From the moment a patient completes a digital intake, the system’s patented DecisionDoc algorithm translates subjective responses into a fully structured clinical document—complete with CPT and ICD codes, validated medical necessity, and audit-ready evidence links.
Each generated Encounter Form undergoes a multi-layered validation process that ensures data integrity, billing accuracy, and compliance with federal documentation standards.
Automated encounter creation from intake and diagnostic data
CPT/ICD code generation based on clinical indicators and local coverage determinations (LCDs)
Medical necessity validation through DecisionDoc’s patented algorithm
Dynamic updates when new labs, imaging, or vitals are added
Physician signature authentication and timestamp tracking
Audit log retention for payer or regulatory review
DecisionDoc’s patented AI-driven clinical engine performs deep analysis on intake and diagnostic data to assist providers in identifying probable conditions and next-step considerations.
This engine does not replace clinical judgment—it enhances it—by offering evidence-backed insights, interpretive support, and intelligent documentation that streamline provider workflows.
DecisionDoc integrates directly with leading diagnostic networks through secure FHIR interfaces.
This allows physicians to order tests electronically, retrieve results in real time, and automaticallyassociate findings with relevant Encounter Forms and medical analyses.
The system’s patented DecisionDoc algorithm verifies laboratory medical necessity before orders aretransmitted—ensuring payer compliance and optimized reimbursement pathways.
Each connection operates through encrypted channels and remains fully compliant with HIPAA andinteroperability regulations.
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Electronic ordering and automated results retrieval
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Medical necessity validation performed through DecisionDoc’s patented algorithm prior to lab submission
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Data auto-mapping to patient records and encounter forms
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Compatible with all CLIA-waived and FDA-cleared laboratory systems
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Integration for multi-location or distributed clinical environments
DecisionDoc integrates billing, auditing, and reimbursement tracking into a single intelligent workflow.
From automated superbills to claims submission, every transaction is verified for coding accuracy and compliance prior to submission.
The platform’s custom-coded revenue automation engine supports eligibility verification, claim adjudication tracking, and underpayment auditing, ensuring practices receive full reimbursement for authorized services.
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Health Information Exchange (HIE) connectivity
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Secure ADT (Admission/Discharge/Transfer) notifications
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High-volume FHIR bulk data export for research and analytics
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Multi-location synchronization with centralized access control
DecisionDoc is built on FHIR (Fast Healthcare Interoperability Resources) to ensure seamless data exchange between EHRs, laboratories, hospitals, and billing systems.
Its enterprise security framework employs OAuth2 single sign-on and granular user access controls—ensuring only authorized personnel can view or modify Protected Health Information (PHI).
DecisionDoc extends beyond internal operations to connect directly with patients.
Through the integrated Patient Portal, individuals can review their records, lab results, and visit summaries securely—while automated scheduling and feedback tools improve engagement and retention.
The optional Rewards Marketplace, driven by DecisionDoc’s validation logic, enables practices to offer incentive-based wellness and referral programs, turning patient satisfaction into measurable growth.
Designed for medical networks, DecisionDoc supports complex user hierarchies and multi-site configurations without sacrificing control or compliance.
Administrators can assign roles, manage credentials, and monitor activity across departments—ensuring transparency and accountability throughout the organization.
Centralized dashboard for all practices, providers, and staff
Role-based permissions with audit visibility
Integrated messaging, tasking, and performance analytics
Cross-location reporting and unified patient data access
User activity logs maintained for minimum six-year retention
Audit-ready administrative access reports
Full compliance with HIPAA Security Rule (auditcontrols)
Every DecisionDoc service is engineered with HIPAA, CMS, and ONC regulations as core architectural principles—not afterthoughts.
The platform’s foundation in FHIR, encryption, and its patented medical necessity algorithm—supported by intelligent validation frameworks—ensures that each process, from intake to billing, is protected, verified, and interoperable.
