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 … Continue reading
Read MoreRecording 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 … Continue reading
Read MoreCan 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 … Continue reading
Read MoreDischarging patients from the hospital is a complex and challenging process. Every year, over 35 million hospital discharges occur in the United States. When a patient moves from an acute care setting to other levels of care such as a … Continue reading
Read MoreA 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 … Continue reading
Read MoreTable of ContentsPre-analytic ErrorsAnalytic ErrorsPost-analytic ErrorsSynoptic Reporting vs. Medical TranscriptionHow Professional Voice-to-Text Services for Physicians Ensure Accurate Pathology Transcripts A pathology report is an important document that guides diagnostic and prognostic decisions. Pathology report accuracy is therefore critical to provide … Continue reading
Read MoreElectronic health records (EHRs) are supposed to enhance the clinical outcomes with faster data input, exchange and retrieval. EHR is regarded as an effective clinical documentation tool to improve the quality of care for conditions for which guidelines are quickly … Continue reading
Read MoreMedical Decision Making (MDM) documentation is as significant as the other two components of documentation (History and Exam) in assigning an evaluation and management (E/M) service level. The end result of MDM is complexity level or severity of presenting complaint. MDM … Continue reading
Read MoreA new study by a group of researchers from the Regenstrief Institute and the Indiana University School of Medicine shows that natural language processing or NLP accurately tracks colonoscopy quality. The presence of adenomas in the colon predicts the patient’s … Continue reading
Read MoreAccurate pediatric documentation is not only essential for effective care and treatment for the child, but also plays a significant role in ensuring patient safety. A UK based study identified different types of pediatric safety incidents and found documentation-related errors … Continue reading
Read More