Yearly Archives: 2014

Electronic Documentation and the Role of Medical Transcriptionists

Though paper-based clinical documentation is transitioning to electronic clinical documentation, a human interface is still relevant to make the technology work optimally and that human interface already exists in the form of skilled healthcare documentation specialists as per the Association … Continue reading

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Better EHR Systems and Documentation for Ebola and Other Infectious Diseases

With the Ebola outbreak, the efficiency of electronic health records (EHRs) in handling infectious diseases has been questioned. This October, representatives from the Centers for Disease Control (CDC) and the Office of the National Coordinator for Health IT (ONC) co-hosted … Continue reading

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Depression Associated with CAD and CVD Risks in Younger Women

A new research found that depressive symptoms in women aged 55 and younger is associated with higher risk of coronary artery disease (CAD) and adverse cardiovascular effects (chronic CVD or cardiovascular diseases) compared to men of the same age and … Continue reading

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Why Accurate Clinical Documentation Is Essential for Bariatric Surgery

Weight loss surgery or bariatric surgery is very effective for severe and medically complicated obesity with associated risks, even death. This treatment is used when less invasive weight loss methods fail. However, there are several risks associated with the surgery itself such as blood clot, excessive bleeding, lung or breathing problems and so on. Continue reading

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Pilot Program at Boston Hospital Provides Patients Electronic Access to Therapists’ Notes

As electronic medical records and secure online portals grow, patients are gaining ready access not only to laboratory findings but also to clinicians’ notes. Certain health care providers with EHR systems give their patients direct access to their health information … Continue reading

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Why Documenting the 4 A’s Is Critical for Opioid Therapy

Though opioid therapy is used to treat chronic pain, accurate and complete documentation of pain management is imperative to reflect the appropriate and legitimate use of controlled substances (substances having the potential for abuse) like opioids, especially when there is increased pressure from regulatory agencies regarding the continuation, or even initial use, of opioids in pain patients. Continue reading

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Transcribing Chart Notes in SOAP Format

Chart notes are dictated in various formats such as a History and Physical Examination (H&P) report with similar headings and less depth, as a single paragraph with few sentences, or using SOAP format. Most physicians rely on medical transcription services … Continue reading

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Informed Consent Documentation for Emergency Care

Though majority of procedures performed in emergency departments (EDs) do not need formal written consent, informed consent is a required process for procedures that have high risks. Documentation of informed consent is very important. If the informed consent is not … Continue reading

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Cloud-based Transfer Improves Data Security and Confidentiality in Medical Transcription

In view of improved productivity and other benefits, most physicians and health care facilities are increasingly outsourcing their medical transcription work. However, a major worry is on maintaining the security and confidentiality of the patient data. To resolve this, established medical transcription service providers are taking several measures to safeguard sensitive client data with cloud-based solutions – hosted transcription services hosted through a secure Internet connection.
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Major Risks Associated with Cloud-based EHR Systems

Though cloud-based EHR systems help to access real-time patient data from multiple locations to enhance clinical documentation and are affordable, there are several risks associated with them. In an EHR system, patient documents are stored on external servers which can … Continue reading

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