Increased Importance of Clarity of Medical Documentation in Patient Care
For a professional medical transcription service, quality is one of the fundamental tenets. Here we examine how quality of medical records can be ensured.
Medical documentation is a major preoccupation of physicians which has to be performed with utmost care and concentration. Ideally, they should be able to do this uninterrupted and in their own preferred style. With most healthcare providers, the dictation-medical transcription process is the most welcome option. With EHRs becoming mandatory, manufacturers are vying to create EHR-integrated mobile speech solution that would provide caregivers with diverse options for capturing and editing dictations and feeding the documentation directly into patient encounter templates within the facility’s EHR system. A recent development in this direction is Entrada’s release of its new module Entrada Rhythm. This module enables caregivers to speed up the capture of clinical documentation and improve the overall quality of the patient’s medical record. Quality no doubt is paramount in healthcare documentation and it ensures patient safety and documentation integrity. For a professional medical transcription service, quality is one of the fundamental tenets. Today, with advanced software and equipment like speech recognition, adoption of electronic health record, template-driven tools for transcription services etc, quality health care records can be achieved.
www.medicaltranscriptionservicecompany.com
1-800-670-2809
Customized Software to Suit Every Caregiver With Entrada Rhythm, administrators and caregivers can choose their preferred documentation workflow (direct EHR input, speech-to-text, transcription). They can change this preference throughout the day as the demands on their time change. Moreover, the system’s patient-centric Mobile Engagement Platform includes a real-time clinical schedule, secure image capture, real-time clinical content synced from the EHR and EHR-integrated secure text messaging. Its mobile editing capability includes the first-ever “clinical keyboard” built specially for editing speech-recognized medical documentation on a smartphone. The caregiver can send the speech-recognized text directly to the EHR templates and self-edit it later, or send it to a medical transcription service company for editing. Organizations have the flexibility to customize the solution for each user – whether it is a surgeon, family practice physician, nurse or other caregivers. So that’s how EHR software is being customized to provide maximum value for users. Meanwhile medical transcription companies also continue to incorporate more features to provide value-added services to their clients. There is no denying the fact that medical transcription as a service will continue to enjoy considerable demand in the healthcare scenario, albeit in a different role maybe. After all, with their vast experience in the field, medical transcriptionists will ensure maximum quality and accuracy for the medical record. A good partnership between the caregiver and the transcriptionist who transcribes and edits the report ensures integrity in healthcare documentation. It is essential for the physician/caregiver to ensure clear, complete and unambiguous dictation. The transcriptionist in turn has to preserve the author’s style and intended meaning. The reports must be transcribed or edited completely. In reliable medical transcription outsourcing companies, the transcriptionists are committed to the documentation process and through continuing education ensure integrity to the process. In addition, they make it a point to report errors and problematic practices that may potentially cause errors and thereby bring more integrity into the process. Guidelines for Maintaining Quality Medical Records That brings us to how healthcare organizations can ensure high quality medical records.
www.medicaltranscriptionservicecompany.com
1-800-670-2809
Health care reports should be accurate and include complete details of the patient encounter
Medical records should be distributed and made accessible to the physicians and other hospital administrators in a timely manner
Medical documents must be reviewed by qualified reviewers in a consistent and impartial manner
Random sampling of medical records should be regularly audited using a complete audio review to ensure that the transcribed/edited documents are accurate
All errors should be brought to the notice of the transcriptionist, editor and/or others who created the report and corrected to improve quality and continuing education
Up-to-date reference materials must be available to all transcriptionists and QA personnel
Quality patient care can be provided only through proper documentation. A more standardized approach towards measuring, reporting and improving the quality of healthcare documentation will surely improve the quality of healthcare documentation and help achieve consistent patient safety outcomes.
www.medicaltranscriptionservicecompany.com
1-800-670-2809