Electronic medical records house different types of reports such as history and physical examinations, operative reports, discharge summaries, inpatient progress notes, consultations, and radiology reports. Reliable medical transcription service companies provide accurate reports in quick turnaround time (TAT). In fact, when it comes to clinical documentation, TAT is an important factor that impacts workflow efficiency, improves data capture, supports clinical decision making, and enhances patient care. TAT may differ for different types of transcribed medical reports. Basically, he timeframe for dictation and placement of a report in the medical record depends on the organization’s policy as defined by state law.
Let’s take a look at the timeframe recommendations for 5 common types of medical reports.
- History and Physical (H&P): According to Joint Commission PC.2.120, a hospital is required to “define in writing the time frame(s) for conducting the initial assessment(s)” and an H&P examination has “to be completed within no more than 24 hours of inpatient admission”. While the timeframes under which the result should be made available is not specified, standard IM.6.10 specifies that “the hospital has a complete and accurate medical record for patients assessed, cared for, treated, or served” and requires a “policy on the timely entry of information” (perspectives.ahima.org). The Joint Commission, however, stipulates when an update to the H&P is required: “when a history and physical (H & P) is completed within 30 days PRIOR TO inpatient admission or registration of the patient, an update is required within 24 hours AFTER the patient physically arrives for admission/registration but prior to surgery or a procedure requiring anesthesia services”. Other points highlighted by the Joint Commission:
- The term ‘registration’ generally refers to patients scheduled for same day or outpatient procedures.
- The 24 hour timeframe begins when the patient arrives at the physician’s office for admission/registration.
- If the H&P is completed greater than 30 days prior to inpatient admission or registration, it cannot be updated. A new H & P must be done.
- A properly documented H&P is valid for the entire length of stay. All changes to the patient’s condition should be entered in the daily progress notes.
- A new H&P or update to the H&P is not required for a patient who remains continuously hospitalized. If the patient has been discharged and later readmitted, a proper H&P (no greater than 30 days) would be needed and it should be updated within 24 hours after re-admission/registration but before a surgical procedure or other procedure requiring anesthesia.
- Operative Reports and High-risk Procedure Reports: These reports have to be dictated and documented immediately after the operative or other high risk procedure. The goal should be to ensure that pertinent information is available to the next caregiver. The Joint Commission’s other notes on operative reports are as follows:
- Immediately after surgery or procedure’ implies “upon completion of procedure, before the patient is transferred to the next level of care”.
- The report can be written or dictated by the surgeon in the new unit or area of care the patient is shifted to after the operation.
- In case the progress note option is used, it must include, at a minimum, comparable operative/procedural report information.
- Discharge Summaries: The components of a discharge summary transcribed by a medical transcription service provider include: the reason for hospitalization, important findings, procedures and treatment provided, the condition of the patient at discharge, and patient and family instructions. All the records should be brought together, analyzed, and completed within 30 days of discharge unless state law specifies another time frame, notes AHIMA. Other time-related elements for a discharge summary:
- The record should be removed from the nursing station as soon as possible after discharge within 24 – 48 hours, but no more than 72 hours after discharge.
- The initial assembly and analysis should take place within 5 days of discharge.
- The remaining time should be used follow up on gaps and track documents that are mailed for completion and/or signature so that the discharge record can be completed in a timely manner.
- Progress Notes: Charts should be completed immediately after treatment when the information is still fresh. It is recommended that progress notes are completed within 24 hours of the appointment. Progress note “float” can be the result of over-scheduled physicians, alert fatigue when supervisors are flooded with alerts to sign a note, and no official deadline to complete progress notes. Facilities need to create their own policies about the timeframe for completing progress notes.
- Radiology Reports: Radiology report TAT is one metric that is frequently used as indicative of radiologist efficiency. The imaging report written is the main method by which the radiologist provides diagnostic interpretation to the referring clinician. Rapid TAT is especially important for reports on patient care provided in the emergency department. Timely imaging reports can help referring physicians make informed decisions about treatment plans and deliver prompt care. A Radiology Key article points out that TAT may differ among stakeholders. For the referring clinician, TAT may be the time from a diagnostic imaging study is ordered until the time when results are received. On the other hand, the radiologist usually considers TAT as the time from when a study is complete and available for interpretation until final signature. The use of voice recognition and structured reporting have been found to improve radiology report TAT and reduce errors. In one study of medical transcriptions, the majority of the respondents reported a contracted TAT for electronic documents of 10 hours.
The adoption of electronic health records (EHRs) has shortened turnaround time requirements for patient healthcare documentation. An experienced medical transcription service provider will adhere to these shortened turnaround times, helping physicians provide safe and timely treatment and care.