EHR
Integrated
Medical
Transcription for Efficient Clinical Documentation
Clinical documentation requires precision. EHR-integrated medical transcription could contribute to this as well as ensure savings.
Medical Transcription Services
Issues with EHR entry have been felt in many healthcare facilities and are traced to various causes -- complexity of the EHR system, inability to attend to the patient and enter details into the system simultaneously, and lack of time being among them. Physicians and other healthcare providers can immensely benefit from EHR-integrated medical transcription from an external provider that will allow access to trained and experienced staff, equipment and technology.
Clinical Documentation Issues in Anesthesia Care Let us consider this with regard to anesthesia care. When it comes to anesthesia care, safety and quality monitoring are critical. Reporting is done based on reliable data gathered through quality indicators and critical incidents. However, incomplete documentation and data underreporting are among the issues identified in anesthesia care. This happens even when computerized data collection is employed. Currently, there is no universally accepted approach to verify the reliability of this data.
Factors hindering quality reporting have been identified as:
Poor and stressed working conditions
Fears regarding legal consequences
Lack of feedback and knowledge in relation to data and results
Causes for EHR Entry Issues One of the major issues with electronic health records (EHRs) is the lag time between nurses’ assessment of patient bedside pain scores and their inclusion into the electronic health records (EHRs). This was analyzed in a 2014 research that was presented at the annual symposium of the American Medical Informatics Association.
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Researchers found that:
Lag times usually varied between 16 and 33 minutes
Patients having lower pain scores as well as larger hospitals had longer lag times
17 minutes was the mean delay recorded for patients having severe pain scores, while no-pain scores had a mean delay of 48 minutes
Around 4% of the surveyed nurses had reported relying on memory alone in the lag time instead of getting the details written down
Being too busy, conversations with patients or family members, grouping pain scores documentation of multiple patients to save time, and forgetfulness were commonly quoted as reasons for delaying EHR entry. The surveyed nurses believed lighter workloads, EHR pain assessment alerts, and mobile devices in units with computer inaccessibility would be solutions to bring down the delay.
EHR-integrated Medical Transcription Can Help As any new healthcare practice takes the steps of progress and success, the workload is sure to increase for the staff. And many of those tasks would involve non-core but essential responsibilities such as clinical documentation. As patients increase, these tasks could consume much time, strain the staff, and compromise on the accuracy of the transcription. Moreover, this could also affect patient care.
The quick approach of ICD-10 implementation also makes it important for practices to make the necessary documentation changes to accommodate the new codes and increase reimbursement. EHR-integrated medical transcription helps ensure efficient
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and accurate entry into electronic health records, where transcribers work directly in the EHR system of your hospital. Patient charts and transcripts are produced right into your electronic record system.
Steps to Get the Strain on Staff Reduced One of the major challenges in doing it all yourself is that it increases the importance of IT management. Practices would need a strong IT department to troubleshoot problems that could strike the various technologies and platforms. Moreover, the IT staff hiring should be made foolproof too.
When EHR-integrated medical transcription is outsourced, it can give healthcare facilities greater time and resources to devote to patient care. It would also reduce operating costs by cutting on in-house EMR entry and charting.
If you aren’t outsourcing, a sudden shortage in staff coupled with the rising volume of dictation could catch you off-guard. That would drastically affect the performance, both in terms of patient care and the transcription or documentation. Getting an outsourcing arrangement in place can insulate you from such fluctuating variables. You wouldn’t have to worry about more and more patients visiting your practice, which is actually a good thing. Let it not affect your workflow, compliance or turnaround time.
www.medicaltranscriptionservicecompany.com
800-670-2809