How Medical Transcription Services Help Ensure Accurate Healthcare Documentation
Medical transcription services can help with accurate, detailed and reliable medical documentation.
MEDICAL TRANSCRIPTION SERVICE COMPANY 8596 E. 101st Street, Suite H Tulsa, OK 74133 Phone : 1-800-670-2809
Medical transcription refers to the process of changing dictations or audio files from medical practitioners into text documents and this helps in maintaining accurate and reliable medical documentation. With the evolution of Medicare CERT and RAC audits and also due to increased review of medical records from payers, detailed and clear documentation has become vital. Medical transcription services can help ensure that. Medical Documentation Should be Clear and to the Point To ensure clarity, the medical documentation should be done without making it too complicated. It should be easy to understand and have all important information about the patients. It is the responsibility of hospital administrators and clinicians to provide a wellstructured medical record that clearly shows the patient’s assessment and the treatment provided. For instance, let us consider the physical therapy specialty and 2 important things that must necessarily be documented in this regard.
Medical necessity
Skilled medical intervention
Both these components must be clearly understood so that these are best described in the medical record. It is important to record these accurately to ensure appropriate patient care, reduced risk to patient, and proper reimbursement for the physician. o Documenting Medical necessity Having all important information about the patient is the first and most important thing. All diagnoses and deficits must be described. A medical document becomes complete with the following information: Patient’s medical history, diagnosis, injuries and functional limitations such as bed mobility, transfers and ambulation. Patient’s current medical status, safety issues and complications. Any service provided must be with the belief that the patient’s health condition will improve significantly within a predictable period of time. Or the services provided must be indispensable with regard to establishing an effective and safe treatment/maintenance program needed for a particular disease condition.
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Treatment provided must be specific for the patient’s condition and it must meet the accepted standards of medical practice. The treatments must be accepted, evidencebased interventions.
o Documenting Skilled Intervention Skilled intervention refers to the services provided by a skilled physical therapist. There are certain skilled intervention criteria such as the following. The patient should be under the care of a physician or non-physician provider such as a nurse practitioner. The services must be provided by a qualified physical therapist or physical therapist assistant. The services must require the knowledge, expertise, clinical judgment, capabilities and decision making of a physical therapist, physician or non-physician provider. The patient’s condition is such that or the services required are of such a level of sophistication and complexity that they can be successfully and safely performed only by a qualified physical therapist or under supervision. For appropriate documentation of skilled information, the physical therapist should record details such as:
Why the particular intervention (s) was/were chosen and why they are still necessary
Observations before, during and after an intervention
The patient’s specific response to the intervention
The type and amount of visual, manual and verbal cues used
Need for Medical Transcription Physical therapy medical transcription will help therapists maintain accuracy in their documentation.
A medical transcription company providing EMR-integrated medical
transcription services would be a good partner in this regard.
Outsourcing medical
transcription to a trusted provider would ensure quicker processing of information and reduce the burden of paperwork. With streamlined documentation, medical billing and claims processing becomes easier and more efficient. Clinicians using these services enjoy a
www.medicaltranscriptionservicecompany.com
1-800-670-2809
double benefit – they will have detailed patient narratives as well as accurate entries in their electronic health record system.
www.medicaltranscriptionservicecompany.com
1-800-670-2809