Efficient EHR Documentation Crucial for ICD-10 MTS Transcription Services
Electronic health record or EHR plays an important role in the success of ICD-10. It serves as the primary diagnosis entry point to capture diagnoses in multiple places. Documentation templates make it easy to capture patients’ data with accuracy and specificity. The export and print features help practices back up easily to support medical necessity. However, it is very important to make your EHR more efficient to reap its real benefits. A combined approach of EHR and medical transcription is significant when it comes to complying with the enhanced specificity of ICD-10.
Ways to Improve Your EHR Documentation
Understand Practice Workflow – With increased specificity of ICD-10, practices should thoroughly understand how it changes the practice workflow and deficiencies with their documentation. They should also understand how it impacts inpatient and outpatient documentation requirements. By getting comfortable with new workflows, you can make better plans for efficient EHR documentation.
Update EHR Templates and Treatment Plans – With ICD-10, practices are required to perform more precise documentation that includes details such as laterality, co-morbidity and anatomic location. Your EHR templates should have the provision to include all these details. The templates should prompt physicians to ask specific questions to their patients. You should also create more specific treatment plans in your electronic record system.
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Capture Specific Patient Data Right at the Beginning – Capture as much information as possible at the very beginning of the patient encounter and enter those details properly in your EHR. This will make the documentation more specific.
Work together with the EHR Vendor – Work closely with your EHR vendor to apply software upgrades related to ICD-10 into your system. This will also help you to request coaching for your staff from the vendor regarding what works well for your practice and what should be discarded. Finally, it will ensure successful transition to ICD-10.
Significance of Blending EHR and Transcription
ICD-10 is more specific, flexible and supports improved measures of healthcare services. The new code system uses current medical terminology while acknowledging various advances in the medical field. As a result, physicians are required to provide more comprehensive information in their records. Although the aforementioned steps can improve the way you document via EHR, there are still some drawbacks and this is why a combined approach of EHR and transcription is very much important. The shortcomings include:
Lack of Comprehensiveness – Though templates provide an easy way to capture specific details, they limit narrative description and this may reduce the comprehensiveness of your report.
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Errors from Using Shortcuts – Practices often use shortcuts for EHR documentation such as copying and pasting information, following favorite lists of diagnoses and so on.
Reduced Quality of Care – While using EHR, physicians may be required to spend time entering the details during a patient encounter. This will prevent them from giving enough attention to patients or what they are saying; and this may in turn affect the quality of care provided.
By blending EHR and transcription, you can eliminate these difficulties and utilize EHR in a better way for ICD-10 success. This approach involves transcribing the dictations recorded by physicians and reviewing the transcripts by clinical documentation improvement (CDI) specialists before populating them into corresponding fields within EHR. Thus, practices can ensure the accuracy of their reports. With the help of medical transcription services, they can save a lot of time to provide appropriate care to patients.
www.medicaltranscriptionservicecompany.com
800-670-2809