2023 HIPAA Compliance Checklist for Small Medical Practices
Enacted in 1996, the Health Insurance Portability and Accountability Act aims to ensure that PHI is protected while providing patients with better access to their health data. Protected health information (PHI) is any information in the medical record or designated record set that can
Modules of a Good Electronic Health Record
Digital technologies are transforming the way the world operates. Electronic health records (EHRs) have all but replaced paper records in modern healthcare organizations, and revolutionized the way patient data is collected, stored, managed and exchanged. Most providers outsource medical transcription to input the medical
How Can You Improve Clinical Documentation?
Clinical documentation comprises all the information relating to each patient’s encounters with a healthcare facility. This information is entered in the medical record by a member of the patient’s healthcare team – a physician, nurse, therapist, dentist or other healthcare professional. Chronologically documenting this
What Are the Common Errors in Medical Documentation?
In healthcare companies, the value of complete and accurate medical records has always been recognized. Medical records give physicians a complete picture of a patient’s medical history so they have everything they need to know when diagnosing or treating a patient. The patient’s health is
How do Medical Transcription Services help Therapists Maintain Good Clinical Documentation?
Clinical documentation is the capture of clinical information at the patient encounter. Clear, accurate, consistent, complete, timely, and legible clinical documentation is necessary to reflect the patient’s condition and provide evidence that the care rendered was meaningful and medically necessary. Behavioral health providers, for instance,
