The Role of MedicalTranscriptionists in the EHR Era
Though changed, professional clinical documentation and medical transcription services that facilitate it are still very much relevant.
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MEDICALTRANSCRIPTIONSERVICECOMPANY
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Traditionally, physician dictation and medical transcription is the way in which patient records are created and maintained. Today, to remain efficient and competitive healthcare organizations are required to quickly enter and maintain accurate structured narrative reports in their EHR systems. The information contained in these reports is important for physicians to understand the healthcare details of the patient and communicate these to other providers partaking in the provision of care. These reports are also important from the viewpoint of financial and medical coding processes. To be used efficiently in the EHR, narrative medical reports must be changed into structured and interoperable patient information available in readable and scannable formats. EHR has transformed medical transcription and the role of the medical transcriptionist. Though changed, professional clinical documentation and medical transcription services that facilitate it are still very much relevant. The Need for Structured Data EHR systems can interface with transcription platforms via HL7 interface and parse data. With the new requirements and innovative technological developments, transcription now creates structured data fields instead of static information snapshots or flat files. Now many physicians use dictation software with advanced speech recognition technology to ensure more efficiency in data transfer. Since manual transcription is not needed with such systems, the transcriptionist now functions as medical editor making sure that the information is accurate. In spite of the pressures of Meaningful Use, many physicians have not yet adopted EHR. Mainly, physicians feel the computer as an intimidating presence between them and their patients. There is also the issue of the EHR being incompatible with the physician’s workflow. How Medical Transcription Can Provide a Solution Let us see how medical transcription can provide a solution for some of these problems physicians face today.
Physicians can use dictation-medical transcription to provide information quickly, and the transcriptionist scrutinizes the documentation before it is entered into the EHR. Physicians can dictate at their convenience –during the patient encounter, in between patients or at the end of the day.
This mode of documentation allows narrative reports and physicians can capture information that cannot be expressed in structured data fields.
Physicians can freely interact with the patients without focusing on the computer screen.
www.medicaltranscriptionservicecompany.com
1-800-670-2809
The transcriptionist functioning as an editor and healthcare documentation specialist can enhance the new NLP (natural language processing)-driven processes.
Validate that the software has accurately captured the discrete data elements and the document structure before it is entered into the EHR. Any error in the EHR is prevented by ensuring that medications, allergies etc are correctly encoded.
They ensure that clinical concepts are correctly encoded before the document is sent to the medical billing and coding department.
They correctly “tag” concepts such as medications and allergies that may have been overlooked.
The EHR transition can be made smooth and hassle-free by effectively using the skill and knowledge of the medical transcriptionist. A valuable documentation tool for the healthcare provider, medical transcription still remains a great option to meet diverse documentation workflow requirements. It can ensure excellent documentation quality, physician satisfaction and also bring maximum returns for providers on their expensive technology investments. Working Together The new trend that we see developing in the healthcare industry is the balanced approach where both EHR and medical transcription are given importance. With accurate medical records patient safety, reimbursements and risk management goals are all satisfied which improves the efficiency of the organization. So, from a practical point of view, medical transcription still plays a vital role in accurate clinical documentation. Work together with a provider of reliable medical transcription services that can ensure confidentiality of your data and also provide error-free data. Outsourcing to a good service provider that offers customized service will prove to be beneficial and economical.
www.medicaltranscriptionservicecompany.com
1-800-670-2809