The electronic medical record (EMR) is a powerful tool that enables the treating physician to track the patient’s medical history and detect patterns or problems, and provide quality health care. Medical transcription outsourcing is a reliable option to ensure accuracy in this living document that tells the patient story. Recent reports indicate that emergency room (ER) electronic health records (EHRs) are prone to errors, which makes quality emergency room medical transcription services really crucial.
Emergency Room EHR Data Entry Issues
Earlier this year, Kaiser Health News reported that electronic records in the ER are breeding grounds for error. The main reason is the chaotic and stressful environment in the ER, where physicians and nurses have to grapple with providing emergency care while entering data in the digitized record systems. According to the report, “poorly designed electronic health record systems are prone to human error, especially in fast-paced emergency room settings”. The patient safety errors that tend to occur are:
- Patient misidentification leading to data entry in the wrong file
- Clicking on a wrong number, resulting in ordering wrong medications or wrong dosages
- Technology mismatch due to the push for interoperability, which is difficult in ER here things happen fast
- Providers need to attend multiple cases, which can be confusing and lead to data entry errors
- EHR model may not be designed for ER use
- Confusing computer displays
- Missing key patient information
- Many systems allow doctors to edit the medical record for only one patient at a time, which makes it harder to keep track of things
The report says that ER EHRs have resulted in new categories of patient safety errors that didn’t exist before.
How Outsourcing Medical Record Documentation can Help
Emergency room medical transcription services can play a crucial role in helping to make the EHR a useful tool for ER healthcare providers. They have expert transcriptionists who can transcribe physician dictation in custom turnaround time – 24 hours or STAT: 2 hours, 4 hours or 6 hours. They accept dictation in various formats such as digital recording or toll-free telephone and provide accurate EHR-integrated transcripts. Partnering with an experienced service provider with a user-friendly document management system can help busy ER physicians avoid data entry errors and manage the patient record efficiently.
The transcription team in a reliable company would be well-versed in the terminology relating to various specialties and can provide error-free, instant reports showing the progress of each file.
Manufacturers should focus on making EHRs useful for the specialty they serve and ensure interoperability among healthcare facilities anywhere in the country. Their design needs to be modified so that errors are minimized and repetitive templates of unnecessary clinical information are eliminated. Professional emergency room medical transcription services can help physicians ensure complete and accurate medical records will meet all legal, regulatory and auditing requirements, and most importantly, contribute to comprehensive and high quality care for patients.