How EHR Documentation Best Practices improve Patient Engagement in Plastic Surgery

EHR DocumentationToday, all medical specialty groups including plastic surgeons have progressed significantly in implementing electronic health records (EHRs). EHR adoption is critical not only from the reimbursement point of view but also as a cost and time saving strategy as paper records are costly and cumbersome to manage. Adherence to EHR documentation best practices is critical for plastic surgeons to improve access to patient information, and enhance patient engagement and retention. Medical transcription companies specialized in plastic surgery transcription can provide affordable EHR-integrated documentation solutions to help surgeons manage, retrieve, and store patient charts easily.

According to an abstract published last September in PRS Global Open, the International Open Access Journal of the American Society of Plastic Surgeons (ASPS), EHR functionality specific to plastic surgery practices include ease of uploading and annotating pictures, management of inventory, documentation of skincare needs and purchase history, and amalgamation with practice management software for medical billing. Other functionality requirements include patient engagement and availability of pertinent patient education materials.

An article in The Aesthetic Channel lists the features of an ideal EHR for plastic surgery practices as follows:

  • Plastic surgery specific EHR system: The EHR system would be specifically designed for this specialty. An ideal system would allow plastic surgeons to manage patient schedules, price quotes, lead tracking, quick charting, lab procedures, procedural notes, patient education and billing. It should also enable the practice to upload scanned documents and photos to patients’ online charts.
  • EHR with comprehensive features: A specialty-specific, single vendor EHR package with comprehensive features offers many benefits. It will allow the plastic surgeon to manage patient documentation, practice management, appointment reminders, inventory management, ePrescribing, insurance billing and patient portal. Feature-rich software will improve interoperability of data, reduce duplicate entries, save time, reduce stress, and improve administrative workflows.
  • Cloud-based software: Modern cloud-based programs offer an affordable way to store and manage medical records. They are a secure, cost-effective option for small practices. A HIPAA-compliant medical transcription company using a secure VPN into the practice EHR or has secure log in credentials if the EHR system is cloud hosted, can ensure secure remote documentation of the plastic surgeon’s notes. On the cloud server, patient files are secure and encrypted and geographically separated data backup is performed automatically. This prevents patient data exposure due to offsite backups or stolen computers and ensures data recovery if a local or regional disaster happens to occur.

While EHRs are transforming the face of plastic surgery, good documentation practices are necessary for tracking patient procedures, educating patients and directly providing them with information, and promoting patient engagement. Documentation errors and critical mistakes can adversely impact patient safety, affect accuracy of coding and billing, lead to HIPAA violations, and increase risk of medico-legal issues. Only an experienced medical transcription company can ensure accurate and timely EHR documentation.

Plastic surgery has its own terminology and language. Trained medical transcriptionists are well versed in these aspects, including types of procedures, surgical incisions and sutures, techniques, patient positioning, and laboratory tests. They can provide error-free reports pertaining to a wide variety or procedures, from chemical peels and dermabrasion to breast augmentation, liposuction, abdominoplasty, blepharoplasty, rhinoplasty, facelifts, reconstructive procedures, and more. By transcribing crucial notes and reports accurately, medical transcriptionists help plastic surgeons provide top quality care.

Plastic Surgery EHR DocumentationEHRs allow accurate, efficient tracking of patient data. Better access to accurate patient data via EHRs benefits both patients and plastic surgeons. Efficient EHR-integrated plastic surgery transcription service offers:

  • Availability of accurate information at the patient’s appointment
  • More time for the patient and less time on EHR data entry and looking up files
  • Accurate and readily available data on current medications, medical conditions and patient blood type on the screen
  • Quick access to information during office visits to present patients with plastic surgery options to meet their aesthetic goals
  • Reduces risk of missing essential elements in patient medical history
  • Improved coordination of patient care

EHRs allow plastic surgeons to send out reminders and improve patient attendance at appointments. By helping the surgeon track patients effectively, digital records also improve patient adherence to maintenance treatments, while improving recovery and reducing the risk of post-surgical complications.

Plastic surgery EHRs also improve patient engagement by allowing patients to participate more effectively in the plastic surgery decision-making process. Armed with information about the different procedures, they can ask questions and schedule appointments at convenient times. Thus, with a well-designed EHR and reliable medical transcription services, plastic surgeons can improve the patient experience, increase patient engagement, grow their practice and boost revenue.