Till recently, most neurologists relied solely on neurology transcription service providers to maintain patient information. Electronic medical record (EMR) systems have made it easier for neurologists to manage patient data more accurately, efficiently, and in a comprehensive manner. They have also made information retrieval simpler. However, experience shows that EMR can increase malpractice risks in documenting clinical findings. An article published in MedScape revealed how this is especially relevant for neurology practices.
Use of wrong template: According to the report, a neurologist had just migrated to a new EMR system and completed a neurologic examination of a one-year-old boy, recorded that the baby boy was oriented as to time, place, and person. This is a serious error as when assessing infants or small children who are not aware about their whereabouts or the time of day, the physician cannot use the same criteria as for adults. The culprit, in this case, was the use of the wrong template.
Though this particular incident did not result in a malpractice suit, it is indicative of the potential problems that neurologists and other specialists face when using the EMR system. If it had, the neurologist would have found it very difficult to defend himself against the charges of wrongly documenting clinical findings.
Increases risk of missing critical information: Another problem relates to the plethora of information that EMRs allow physicians to enter few keystrokes, a checkmark or the push of a button. The software allows them to provide a detailed description of a comprehensive examination and list negative findings. The pitfall is that it is very difficult for the physician to review such repetitive documentation. As a result, the risk of missing important details, and consequently malpractice, increases.
Diverts attention from the patient: Entering information into the EMR could divert the neurologist’s attention from patient signs and symptoms. This is a potentially a great malpractice risk.
Role of Neurology Medical Transcription
Industry experts recommend a blended approach or integrating medical transcription and EMR. This would offer many benefits for a neurology practice:
Increases accuracy: With their in-depth knowledge of neurology terms and procedures, medical transcriptionists can improve the quality of clinical documentation by accurately transcribing the details of a patient visit. These can be fed into the EMR and no critical details would be missed.
Greater visibility of findings: By documenting clinical findings clearly and placing them in a separate section of the record, transcriptionists help neurologists find critical information easily when it is needed.
Efficient use of different documentation modalities: Structured history and physical templates populated by a physician assistant may be used certain care settings. On the other hand, narrative reports that are dictated and transcribed could be the best option when documenting inpatient discharge summaries, encounter notes, findings, and assessments in a neurology practice. This also minimizes errors.
Better focus on patient care: Neurologists can also reduce risks of malpractice with transcription-integrated EMR as it allows them to focus more in patient care.
In addition to avoiding hidden malpractice risks, using the services of a professional neurology transcription company helps physicians improve productivity, efficiency and workflow.