Medical Transcription Services enable Proper Recording of Patient Symptoms

Medical Transcription Services enable Proper Recording of Patient Symptoms

Proper recording of patient symptoms and other data in the EHR is crucial for accurate diagnosis and a medical transcription company can ensure this.

www.medicaltranscriptionservicecompany.com

MTS Transcription Services United States

(800) 670 2809

Accurate, credible medical records with precise information about the patient’s symptoms lead the physician to correct diagnosis. Medical transcription companies play a key role in helping healthcare providers maintain good documentation that protects the patient.

Electronic medical records (EMRs) can be considered reliable only if they contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and result of the treatment accurately. However, Reuters recently reported that a new study showed that medical records don’t always describe what patients actually say.

New Study reveals Patient Questionnaire-EHR Documentation Mismatch The report, which was published in JAMA Ophthalmology,showed that symptoms that patients describe to physicians may not always be documented in EMRs.The small study was based on an evaluation of paper-based eye symptom questionnaires completed by 162 patients who visited eye clinics between October 2015 and January 2016. The key findings of the report are as follows: -

About one-third of the time, information on blurry vision from patients’ paper questionnaires didn’t match the electronic record

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In cases where blurry vision was the most common complaint, the EMR was correct in 60 cases, but failed to note this correctly in 25 cases

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In cases where blurry vision was not reported, the electronic records accurately noted this in 26 cases but incorrectly identified this as a problem for 29 patients

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A high incidence of discrepancies was noted for other symptoms such as redness, pain, glare, itching, gritty sensation and sensitivity to light.

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In most cases, the mismatches were due to EMRs failing to capture symptoms which patients noted on the paper questionnaires.

The findings of the study led one expert to remark on the criticality of data accuracy in patient medical records.

“Documented signs and symptoms play an important role in efficiently steering providers towards the correct diagnosis and treatment, and medical records also serve as a means of communication between members of a patient’s healthcare team… any inaccuracies in the record could potentially threaten or delay patient care,” said Dr. Christina Weng of the Cullen Eye Institute and Baylor College of Medicine in Houston.

www.medicaltranscriptionservicecompany.com

(800) 670 2809

Medical Transcription Services for Comprehensive Medical Documentation U.S. based medical transcription service companies play an important role in helping providers maintain accurate electronic health records (EHRs). These services are available for

all

specialties

including

ophthalmology.An

experienced

company

can

ensure

comprehensive,accurate and timely EHR-integrated ophthalmology transcription service for ophthalmic care clinics, hospitals, individual and group practices, and to overcome the issues revealed by the above-mentioned study.A reliable service providercan helpphysicians maintain EMRs that contain all information required for diagnosis and care: -

history and physical

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subjective complaints

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examination results

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physician notes

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test results, including x-rays

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objective assessments

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treatment plans

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operative reports

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reports of consultations and hospitalizations

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medications prescribed, dispensed, or administered

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description of the actual treatment provided

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discharge summary

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copies of records or other documents obtained from other providers

By providing comprehensive, accurate and timely EHR-integrated documentation, an experienced medical transcription company helps providers improve the quality of care and lower the costs associated with errors. Patient data accuracy also reduces medico-legal risks for physicians and helps makes electronic health records reliable tools for researchers mining data.

www.medicaltranscriptionservicecompany.com

(800) 670 2809