This is the age of electronic health records and an increasing number of providers are transitioning to it from traditional paper records. However, the structured documentation characteristic of EHRs prove challenging to physicians who find it difficult to represent the complexities of their patients’ conditions within checkbox templates. Many physicians would rather use traditional dictation and medical transcription rather than the point and click, predesigned templates. When physicians fail to create a comprehensive medical record using the EHR system, considerable delay may occur in making the necessary information available when needed.
However, EHR and medical transcription can go hand in hand to make medical records timely, accurate and effective. To ensure timely medical records and superior patient care, the best solution is to utilize full dictation and transcription along with EHR. Physicians can continue with their dictation practice, and complete their medical records on time without disrupting their workflow.
ICD-10 documentation can be error-prone because of the larger volume of data involved. Trained physicians can dictate the required information to be entered into ICD-10-compliant templates. Transcriptionists can enter the data into a concise file format. The transcriptionist needs to ensure that each detail is recorded in the correct field. They will review and edit the document to make sure that the information is entered accurately. All the components in a template should be documented carefully because missing or incomplete information can delay reimbursement and invite excessive queries from other practitioners regarding patient care.
Organizations that opt for partial dictation can have the transcribed section of the report uploaded to the respective EMR and merged with the relevant check-box information.
Documents created via voice recognition software can benefit from the intervention of a human transcriptionist who will review and edit the document, ensuring that the dictated information is included under the proper headings for each template design. Here, any missing information is flagged so that physicians can edit it when they receive the transcribed document.
Transcriptionists have a lot to contribute even in this EHR age.
- They can capture the complexities of medical conditions and provide a comprehensive report of specific patient situations.
- They will ensure remarkable accuracy of the details entered and thereby ensure patient safety and reliability of the medical record.
- They serve as transcriptionists typing out a full report, and as editors ensuring the accuracy of medical record information in a speech recognition document or verifying EHR information.
EHR combined with medical transcription provided by a reliable medical transcription company can ensure better documentation, accuracy and improved patient care.