In the healthcare industry, proper and accurate clinical documentation is a necessity both from the point of view of patient care and from that of physician reimbursement. Inaccurate medical records can compromise patient safety, and also lead to filing of inappropriate claims. Until now, the standard practice has been dictation—medical transcription, with the transcription being done either in-house, or by a medical transcription company. Now EHRs have been introduced and made mandatory, which have both positive and negative characteristics. Among the helpful features of EHR are those that assist with documentation. The software may reduce the complexity of writing documentation. However, this information needs to be verified for each patient encounter to avoid issues such as copy-paste and populating inaccurate information in the EHR. Healthcare providers who find it difficult to use EHR can benefit from a blended approach,
combining
traditional
dictation—transcription
and
EHR.
Documentation
processes in the healthcare organization can be simplified, error rate reduced considerably, and documentation prepared more efficiently in this way. Let us consider how providers can make the best use of their EHR systems. Use of SOAP Notes for Comprehensive Documentation Soap notes are standardized medical evaluation entries made in clinical records. They facilitate better communication among healthcare providers, and between physicians and patients. Soap notes may be longer for a patient who is visiting for the first time. It includes all the basic details of a patient. It is flexible and different healthcare providers have their own styles of writing the SOAP note. Documentation of SOAP notes should be very specific and correct information should be entered. It will enable healthcare providers and hospitals to stay away from any kind of malpractice and also helps at the time of auditing. Maintaining precise Soap notes ensures better patient care and quality service. Have a Clear Understanding of EHR Documentation EHR is a digital version of a patient’s data that can be collected and managed by multiple authorized healthcare providers. It consists of information about a patient, gathered by organizations over a period of time. It includes demographic data, medical history and clinical information such as lab results, pharmacy data etc. It is an efficient way to improve clinical workflow, data analysis and overall patient care.
www.medicaltranscriptionservicecompany.com
1-800-670-2809
While it is true that a good EHR system can guide providers through the documentation process, it is vital that providers are aptly trained in EHR documentation practices. Only then can they identify strategies to simplify documentation, stay in compliance and streamline documentation. Use EHR Templates Wisely Templates are characteristic of EHR systems and have to be used correctly. Providers can copy documentation provided they adjust and customize the information to the particular patient and for that particular encounter. If providers copy-paste the information from one template to another without customizing, it can lead to serious consequences for both the patient and the medical practice. Follow necessary guidelines to ensure great documentation and also sign each entry with your initials and a time and date stamp, which will remind you when a template is in use and needs revision. For efficient documentation of patient healthcare details, the ideal option is to hire medical transcription services that can offer error-free and accurate medical records. Healthcare providers can choose a medical transcription company that has HL7 interfacing capability and offers EHR-integrated medical transcription. There are highly reliable vendors based in the U.S that utilize the best resources in terms of technology and transcription personnel. A good outsourcing partner will help increase the productivity and profitability of your healthcare organization and provide cost-effective services.
www.medicaltranscriptionservicecompany.com
1-800-670-2809