Valid, accurate, complete, trustworthy, and timely electronic medical records improve the utility of clinical documentation, and enhance communication between healthcare providers. One of healthcare’s worst nightmares is wrong information in the medical record. As a medical transcription company in the … Continue reading
Read MoreThe health of the patients is the most crucial aspect of any medical practice, including dental practices. However, keeping track of and managing patient records is a challenge for many dental clinics. This might result in expensive errors such as … Continue reading
Read MoreAccording to ICD Coding Guidelines, all conditions co-existing at the time of the encounter that require or affect patient care and management must be clearly documented and assigned a diagnosis code. Each diagnosis must be documented clearly and precisely by … Continue reading
Read MoreAll physicians know that patient outcomes depend on successful communication. Open communication can help providers obtain more complete information from patients, improve the prospects of a more accurate diagnosis, and promote proper counseling, thus potentially improving patient adherence to treatment … Continue reading
Read MoreTable of ContentsWhy CDI is Vital for Patient CarePurposes of Clinical DocumentationStrategies to Improve EHR Clinical Documentation and Save Physicians’ TimeOther RecommendationsBenefits of Clinical Documentation Improvement Clinical documentation comprises all the information relating to each patient’s encounters with a healthcare … Continue reading
Read MoreTable of ContentsClinical Documentation in Behavioral HealthRole of Mental Health Transcription Services Clinical documentation is the capture of clinical information at the patient encounter. Clear, accurate, consistent, complete, timely, and legible clinical documentation is necessary to reflect the patient’s condition and … Continue reading
Read MoreTable of ContentsProblems Associated with the Use of Medical AbbreviationsCareless use of medical abbreviations and acronyms in the medical recordCommon Medical Abbreviation Errors Medical abbreviations and acronyms or “acceptable” terms that physicians and other healthcare professionals generally use in patients’ … Continue reading
Read MoreTable of ContentsTranscribing Medication Orders Medication Transcription ErrorsPrevent Medication Documentation Errors with Outsourced Medical Transcription Services Many prescriptions are now computer-generated, but may also be hand-written and paper-based. In many healthcare systems, nurses are responsible for medication transcription, which involves … Continue reading
Read MoreTable of ContentsNeed for Effective Time ManagementStrategies for Physicians to Save Time for Patient Care Getting important work done in a day is every professional’s dream. For physicians, efficient time management can ensure more time to provide quality care. When faced … Continue reading
Read MoreMedical records are a fundamental element in the provision of patient care. Good clinical records aid – coordination and continuity of care, and informed decision making for patient management. It can also improve availability of data for malpractice litigation. Patient … Continue reading
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