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Efficient Documentation for Improved Clinical Encounters

Medical TranscriptionIn the healthcare industry, proper and accurate clinical documentation is a necessity. Today, the healthcare landscape is shifting and medical documentation has become more strategic and imperative. Medical records include details about an individual’s health history and other clinical data that optimizes medical claim processing.  With the help of a reliable medical transcription service, the increased demand for accurate and timely medical documentation can be met efficiently. Efficient documentation of medical records helps healthcare professionals provide better patient care and improve their medical organization.

Use of SOAP Notes for More Efficiency

Soap notes are standardized medical evaluation entries made in clinical records. These facilitate better communication between healthcare providers and the patient. Soap notes may be longer for a patient who is visiting for the first time. They include the basic details of the patient. It is flexible and different healthcare providers have their own styles of writing the SOAP note. These notes should be very specific and contain the correct information. It will help healthcare providers and hospitals to stay away from any kind of malpractice liability and also helps during an audit. Most importantly, since you have more comprehensive patient history and care records, you can also ensure better patient care and quality service.

Effective Use of EHR Documentation

EHR is a digital version of a patient’s data that can be collected and managed by multiple authorized healthcare providers. It contains all information about a patient, gathered by organizations over a period of time. It includes demographic data, medical history and clinical information such as lab results, pharmacy data and other details. It is an efficient way to improve clinical workflow, data analysis and overall patient care.

  • Good EHR systems assist with accurate and efficient documentation. They help reduce the complexity of writing down notes.
  • They help reduce paperwork costs.
  • It is important that you verify the information entered by the software during each new patient encounter.
  • Ensure that you are properly trained in the use of your EHR system.
  • Make good use of the medical templates to ensure better patient encounter.
  • Make it a point to sign each entry with your initials as well as a date and time stamp. This will remind you when a template should be used and modified.

Partnering with a Medical Transcription Company for Improved Efficiency

In the current healthcare scenario with EHRs becoming mandatory and physician workload increasing, a practical solution for healthcare providers is to hire a good medical transcription service that can offer error-free medical records. They use advanced technology and equipment to ensure prompt services customized to your requirements. You need to find a medical transcription company that offers EHR-integrated medical transcription. This is a good option for physicians who prefer dictating their notes and focusing more on patient interaction. Your dictations will be transcribed by professional transcriptionists, who will then enter the details into the EHR templates so that your EHR documentation will also be streamlined.

About Rajeev Rajagopal

Rajeev Rajagopal

Rajeev Rajagopal is the Vice President of Managed Outsource Solutions, a leading BPO company in Tulsa, Oklahoma. He has extensive knowledge in SEO, medical billing and coding, and medical transcription. He has worked with a number of large organizations to effectively manage and provide outsourcing solutions.

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