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Study: Significant Lag Times Exist between Evaluating and Documenting Patient Pain Scores

Study: Significant Lag Times Exist between Evaluating and Documenting Patient Pain Scores

When it comes to nursing transcription, frequent documentation of pain scores is very important for proper pain assessment and treatment. However, the study findings presented at the American Medical Informatics Association’s 2014 annual symposium highlight a significant delay on the part of nurses in documenting bedside pain scores. Pain score generally indicates the intensity of … Continue reading Study: Significant Lag Times Exist between Evaluating and Documenting Patient Pain Scores

Medical Transcription Could Address the Problem of Inconsistent EHR Documentation

Medical Transcription Could Address the Problem of Inconsistent EHR Documentation

Recording of physician notes and subsequent medical transcription to create transcripts is an effective means of ensuring that all clinical details are correctly documented. However, the entry of electronic health records has changed this practice and providers are now required to enter patient details into the EHR system. Work pressure, difficulty to attend to the … Continue reading Medical Transcription Could Address the Problem of Inconsistent EHR Documentation

Disparities in Electronic Charting of Allergy Information – Is EHR Transcription a Better Option?

Disparities in Electronic Charting of Allergy Information – Is EHR Transcription a Better Option?

Can electronic medical records eliminate the need for accurate medical transcription? This is a question frequently asked by providers who are used to dictating their medical notes and having them professionally transcribed. Let us consider this in the light of the findings of a recent study. Complete and accurate documentation of medication allergies is crucial … Continue reading Disparities in Electronic Charting of Allergy Information – Is EHR Transcription a Better Option?

Surgical Errors on the Rise, Keep Your Operative Reports Accurate

Surgical Errors on the Rise, Keep Your Operative Reports Accurate

A new state report covering Connecticut hospitals found that the number of adverse events in hospitals and other healthcare facilities reached 500 in 2013 i.e. double the number of 244 incidents reported in 2012. When it comes to surgical adverse events, there is a large increase in perforation during surgery. The number of patients harmed … Continue reading Surgical Errors on the Rise, Keep Your Operative Reports Accurate

Quality Anesthesia Documentation – Barriers and a Possible Solution

Quality Anesthesia Documentation – Barriers and a Possible Solution

Documenting vitals and patient history during pre-op anesthesia is time consuming while recording vitals in the post-anesthesia care unit (PACU) will take away a significant portion of time dedicated for patient care. Electronic anesthesia documentation is considered a fast and efficient method that ensures clear communication among providers and diligent patient care. However, underreporting of … Continue reading Quality Anesthesia Documentation – Barriers and a Possible Solution

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