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 … Continue reading
Read MoreTable of ContentsPurposes of Clinical DocumentationStrategies to Improve Clinical DocumentationBenefits of CDI 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 … Continue reading
Read MoreTable of ContentsFour Main Reasons to Ensure Proper Medical DocumentationCommon Errors in Medical RecordsOther Medical Errors In healthcare companies, the value of complete and accurate medical records has always been recognized. Medical records give physicians a complete picture of a … Continue reading
Read MoreTable of ContentsClinical Documentation in Behavioral HealthRole of Mental Health Transcription Services 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 … Continue reading
Read MoreAutomation has disrupted many industries, and improved productivity by doing away with tasks that involve a high level of physical work and repetitive tasks. Healthcare is also benefiting from automation. One of the most common examples of automation in healthcare … Continue reading
Read MoreA medical report provides a detailed account of a patient’s medical history, current condition, and treatment plan. Medical reports can be written by a variety of healthcare professionals, including doctors, nurses, and therapists, involved in a patient’s care. These reports … Continue reading
Read MoreTable of ContentsProblems Associated with the Use of Medical AbbreviationsCareless use of medical abbreviations and acronyms in the medical recordCommon Medical Abbreviation Errors Medical abbreviations and acronyms or “acceptable” terms that physicians and other healthcare professionals generally use in patients’ … Continue reading
Read MoreTable of ContentsImpact of Physician EHR Data EntryTop Benefits of Medical Transcription Services The role and responsibilities of physicians have expanded considerably over the last two decades. From the dynamics of the healthcare system, rapid advances in technologies, and … Continue reading
Read MoreAs we are heading to a New Year, here’s a review of our most insightful blog posts of 2022. We are experienced in providing reliable medical transcription services for healthcare clients across the United States and worldwide. Our top blogs … Continue reading
Read MoreTable of ContentsTranscribing Medication Orders Medication Transcription ErrorsPrevent Medication Documentation Errors with Outsourced Medical Transcription Services Many prescriptions are now computer-generated, but may also be hand-written and paper-based. In many healthcare systems, nurses are responsible for medication transcription, which involves … Continue reading
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