Accurate and Timely Documentation Crucial for Overweight and Obesity Management Family practice medical transcription becomes significant with regard to documenting overweight and obesity data in a family practice setting.
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Overweight and obesity are among the most common health problems that affect Americans. According to the Centers for Disease Control and Prevention (CDC), more than half of adults aged 20 years and more are overweight, including obese individuals. The treatment for overweight or obesity problem involves two crucial steps assessment (determination of the degree of obesity and health status) and management. Overweight and obesity management includes not only weight loss and maintenance of body weight, but also measures to tackle other risk factors. Primary care physicians can help their patients in this regard providing the right advice and recommendations for a healthier lifestyle. Treating physicians can ensure proper care and follow-ups via accurate and comprehensive documentation. Family practice medical transcription becomes significant in this regard.
Since obesity is a chronic disease, it requires lifelong effort for successful treatment. Individuals at lesser risk will require counseling and a change in their lifestyle to reduce weight or maintain low body weight. People who can’t achieve reduction in body fat may require weight loss therapy to prevent weight gain. For more serious cases, dietary therapy, behavioral therapy and pharmacotherapy may be required. However, physicians should consider the patient’s risks, reason and motivation for weight loss, time availability, previous attempts at weight loss and several other factors when providing recommendations for weight loss. Complete documentation of patient evaluation, history and other details will give physicians a clear picture of the patient’s condition and help them give the right recommendations.
Crucial Elements in Obesity Documentation
BMI Score or Percentile – Body Mass Index (BMI) is an estimate of body fat that is calculated from an individual’s height and weight. BMI score is a good gauge to identify the risk for diseases that occur from excess body fat. BMI percentile is plotted by comparing heights and weights against growth charts that take age
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and sex into account. BMI-for-age percentile shows how an individual’s BMI compares with other individuals of the same age. Either physicians or nurses document BMI after the assessment.
Weight Classification – The documentation must not only include BMI, but also at least one weight classification from the list given below depending upon the BMI score or BMI percentile.
BMI-for-Age Percentile Less than 5th percentile
Underweight
5th percentile to less than the 85th percentile
Healthy weight
85th percentile to less than the 95th percentile
Risk of overweight
95th percentile or greater
Overweight
BMI
18.5–24.9
Normal weight
25.0–29.9
Overweight
30.0–39.9
Obese
40.0 and above
Extreme obesity
Co-morbid Conditions – Certain diseases or risk factors associated with obesity can put the patients at high absolute risk for subsequent mortality. It is very important to document such conditions as they require aggressive management. These may include coronary heart disease, other atherosclerotic diseases, hypertension, cigarette smoking, type 2 diabetes, and sleep apnea.
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Which Is More Efficient – EMR or Transcription?
Electronic medical records or EMRs improve documentation and tracking of weight and other health indicators to ease the referral process and thereby provide opportunities to enhance both care coordination and quality of care. The benefits of using EMRs for obesity documentation are as follows.
Electronic record systems have the ability to improve the consistency of data collection, BMI calculation and trend information for each patient.
With EMRs, it is possible to use the patient data collection to examine the effectiveness of treatment for the patient population under an individual physician or across the practice as a whole.
In the case of integrated practices, EMRs allow all physicians involved in the case to access not only the information on the referral form, but also the entire picture of the patient’s health. This improves coordination and results in a better treatment program for the patient.
EMRs make the referral process easier outside integrated practices and in certain cases allow coordination with the receiving physician.
Overcoming EMR Challenges
However, a 2014 study revealed that obesity is underreported in electronic medical records. The study found obesity is not documented in the EMR problem list despite the presence of obesity BMI in the patient EMR. It was also found that the diagnosis of obesity was documented more often for certain types of co-morbid conditions (for example, sleep apnea) and less often for certain other types. The study explains that www.medicaltranscriptionservicecompany.com
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since around two-thirds of American adults are either overweight or obese, primary care physicians found it too overwhelming to deal within the context of their practices.
EMRs pose certain issues for physicians who are finding the transition challenging. Confusion regarding adding information, possibility of copy-paste errors and limitation to narrative description are some of those problems. Medical transcription is still relevant and can prove to be an efficient support to physicians who prefer the old mode of dictation for recording patient notes. It allows a third party to ensure that the patient data is accurate and consistent. Practices can adopt a combination of EMRs and transcription so that they can have the benefits of both EMR and transcription. EMR integrated transcription involves transcribing physician recordings with the help of skilled and experienced transcriptionists, reviewing the transcribed data and populating the details into corresponding EMR fields. Primary care physicians can rely upon professional medical transcription companies to streamline and manage patient documentation. Companies with a long track record in the industry are sensitive to the requirements of their clients, ensuring confidentiality for the information shared and excellent accuracy through three-level QA process.
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