EHR for Clinical Notes – An Analysis

Clinical notes are records that summarize the interaction between patients and healthcare providers, and are central to patient care. These may include notes from outpatient visits, inpatient admissions and discharges, procedures, protocols, and testing results. The process of documenting clinical care covers the diverse domains of patient care, clinical informatics, workflow, research and quality. As electronic health records (EHRs) are widely used by providers now, there is growing emphasis on structuring clinical notes to reuse data for subsequent tasks. However, generating clinical notes for an electronic record system is a challenging task.

QA in Clinical Documentation in the Current Healthcare Scenario

With EHR and speech recognition systems, clinical documentation quality has become more important than ever, since the documents are often shared among multiple providers. Both patients and providers depend on these documents and so these have to be free of errors. However, the question is whether Quality Assurance (QA) of documents is adequate under the current developments in healthcare documentation? According to the president of the Association for Healthcare Documentation Integrity (AHDI), QA process is there within healthcare organizations that have in-house departments and the transcription service organizations that provide transcription services to the hospitals. The QA standards are inconsistent as each company / department develops their own standards to define quality documentation.

Being a Medical Transcriptionist – Tips to Improve Your Skills

Often, the role of a medical transcriptionist is challenging as it requires them to handle sensitive patient records comprising confidential information. Maintaining the confidentiality and security of medical records is very important in the medical transcription job. No matter how experienced the medical transcriptionists are or how much they may have transcribed, errors are bound to occur.

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