Clinical documentation improvement ensured by a good medical transcription company is indispensable in the current scenario when the healthcare industry is experiencing a shift to a value-based system of care that is driven by technology and consumerism. At present, patients who are the consumers have technology in their hands that enable them to ask relevant questions related to their medical conditions and also understand their conditions better. With increased transparency assured by new technological advancements, healthcare organizations need to become more efficient and responsive if they are to present quality performance and maintain revenue.
Importance of Consistent Charting of Medical Information
So how is documentation important? Accurate medical documentation reflects the efficiency of physicians and the quality of patient care provided in the healthcare setting. Keeping a record of all relevant patient data helps the physicians to monitor the treatment given to the patient and reduce the chances of risk. With timely and accurate medical transcription, healthcare data can be quickly transcribed and entered into the EMR system. This data can be reviewed, edited and stored for future references. To ensure good patient care and promote excellent clinical practices, healthcare units should focus on minimizing possible documentation errors.
Avoiding Documentation Errors
- All entries in the medical records should be kept in black ink to ensure clarity and physicians should not alter the medical records. This is because if there is any legal issue, an attorney with the help of document examiner can identify any modifications made in the medical chart. This can damage the credibility of the physicians as well as the healthcare unit.
- Recording each patient’s name or identifier on each page of the record every year is important. This will help prevent errors at the time of photocopying or scanning documents or while merging documents. Entering accurate date and time of all medical encounters and events as well as the patient’s name in the medical records is essential.
- If there are any mistakes in the medical records, strike out the incorrect information with a single line and write the correct information with date and time. This can clearly show the details that were removed and the corrections made. Correcting data using whitener or scribbling out is not acceptable.
- The dictated records should be verified thoroughly before sending out. The medical records should have the name of the physician who treated the patient and the records should be signed by the relevant clinician.
- Many doctors have poor handwriting that others find difficult to read. Medical records should be clear, legible and free from any errors so that any caregiver who reads the records can understand the condition of the patient and provide care accordingly.
- Using abbreviations in the medical records saves time but make sure that you use only standard abbreviations.
- In the case of non- compliant patients, ensure that all information like missed appointments, frequent cancellations, failure to do recommended exercise or refusal to stop certain activity is recorded correctly.
- A busy doctor tends to record only abnormal findings in the record and ignores minor changes; this is a dangerous practice that could be fatal for the patient. So, all abnormal as well as normal findings should be recorded for effective patient care.
How a Medical Transcription Services Company Can Help
- Accuracy can be ensured for medical documentation with the support of medical transcription services.
- Physicians can document patient details and care provided through narrative dictation. They need not spend valuable time handling rigid EHR templates and be bogged down by inherent limitations of the electronic health record system.
- A reliable service provider would help avoid any lack of specificity in clinical documentation that can compromise quality care and financial outcomes.
- Physicians are ensured documentation that clearly portrays the complexity and severity of the patient’s health condition and the services provided to effectively address the condition.
- Providers will be able to enhance the quality of patient care and obtain reimbursement in keeping with the services provided.
With reliable services, physicians can clearly record all their services and accurately document patient details and the interactions with the patients. This will ensure compliance, enhanced patient care and timely reimbursement in the current scenario with its new value- and outcomes- based payment model.