Study: Electronic Health Records and Scribes can Improve Workflow in Allergy Practices

04-April-2023 MTS TEAM EHR Transcription

Electronic Health Records

The electronic health record (EHR) offers many advantages and have made documentation and provision of care easier for healthcare providers. As of 2021, nearly 4 in 5 office-based physicians (78%) and nearly all non-federal acute care hospitals (96%) had implemented a certified EHR, according to HealthIT.gov. EHR adoption has also increased in all specialties and many providers rely on outsourced medical transcription services to manage their documentation. The use of EHRs and medical scribes is an effective way to boost workflow and efficiency in the modern allergy and immunology clinic, according to a study published in Current Allergy and Asthma Reports in 2020.

Advantages of EHRs for Allergy Practices

The EHR system provides multiple benefits for allergy practices:

Offers a centralized storage location for patient health information in legible format
Provides quick access to patient records from anywhere, including remote locations
Ensures immediate and easy access to patients’ allergy history, medication usage, and treatment plans
Streamlines record-keeping processes
Interfaces with labs, registries, and other EHRs
Enables enhanced, rapid, effective communication
Reduces risk of medication errors and duplicate information
Improves care quality with enhanced decision support, clinical alerts, reminders, and medical information
Improves compliance in immunizations
Reduces costs and saves time searching for patient charts

The study authors noted that accurate and complete EHR documentation leads to improved patient charge capture and reduces billing errors. They also listed EHRs’ Allergy/Immunology specific attributes – recording allergy skin testing documentation; immunotherapy dose customization; administration, and documentation; incorporation of extract ordering, interface with pulmonary function testing and integrating questionnaires such as asthma control tests.

In addition to supporting providers, the EHR also provides many advantages for patients. The system facilitates appointment scheduling, reduces the need to fill out the same forms at each office visit, and sends notifications to providers about point-of-care data and important health interventions. E-prescriptions are electronically sent to the pharmacy. Patients can use the system’s patient portal to communicate with providers and receive electronic referrals for follow-up care with specialists.

However, despite their many benefits, in practice, EHRs can be time consuming to use on a daily basis. Providers point out that patient interaction can suffer when they perform EHR data entry during consults. EHRs also contribute to physician burnout.

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Study: Scribe Support can Ease EHR Documentation

According to the study authors, implementing various strategies to support EHR use can help allergy practices streamline workflow, improve job satisfaction, and reduce physician burnout. The study provided evidence to show that scribe support can significantly improve documentation and workflow efficiency in medical practices:

Reduces patient visit duration: A 2018 oncology study found that when physicians were provided scribe support in the clinical setting, there was a 12.1% decrease in the overall patient visit duration compared to previous clinic visits without scribes.

Increases productivity and reduces costs per patient: A large outpatient urology office 2017 study reported that productivity (measures as both office evaluation and management visits and total relative value units) significantly improved by bringing in scribes. Another comprehensive study of emergency physicians reported that presence of scribes was associated with productivity gains, as measured by the mean number of patients per hour per physician. Making use of a scribe was also associated with reduced length of patient stay and costs per patient.

Promotes optimal use of office staff and reduces physician stress: Research suggests that addition of scribes can promote optimal use of office staff and proper delegation, and improve job satisfaction, and reduce physician burnout.

Methods for integrating Scribes into Practice

Scribes can participate in the clinical setting in different ways:

Taking additional history before the provider sees the patient
Annotating/transcribing medical notes in the room with provider
Inserting the provider’s template note into the medical note (not in the patient’s room)
Inserting the provider’s dictated note into the medical note (as done by medical transcription outsourcing companies)
Using voice recognition

Allergists can choose the scribe integration method they are comfortable with based on the needs of their practice and their patients. While some physicians want to actively participate in the documentation process, many others prefer outsourcing medical transcription where the scribe takes on as much responsibility as possible to create accurate and timely EHR documentation. In fact, outsourcing comes with distinct advantages for busy allergists:

Accuracy: Experienced medical transcription service providers employ trained transcriptionists who are knowledgeable about medical terminology and allergy-specific information and can ensure a high accuracy rate of 99%.
Turnaround time: Quick turnaround time is crucial to ensure timely treatment and care for patients. By partnering with an expert, allergy practices can enjoy a TAT of 24 hours or less.
HIPAA compliance: Allergy practices should make sure to choose a HIPAA complaint transcription service that has proper security protocols in place to protect patient information.
Customized solutions: A reliable medical transcription company will adapt to allergy-specific templates and workflows to customize their services to meet the unique needs of allergy practices.
EHR integration: By seamlessly integrating with the allergy practice’s EHR system, a medical transcription service provider can ensure easy transfer of transcribed information.
Cost: Costs of allergy and sleep medicine transcription services can vary. Allergists can compare services and costs and choose the company that can provide value for money.

With the large number of service providers out there, choosing the right medical transcription company in the US can be a challenge. Allergists should carefully evaluate their requirements and make sure that the company they choose can provide accurate and timely allergy documentation solutions that meet their unique needs.

We can ensure a high level of transcription accuracy required to enhance patient care delivery and workflow efficiency.

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How Human-based Medical Transcription Services improve Healthcare Communication, Care and Efficiency

30-March-2023 Julie Clements Medical Transcription

Healthcare Communication

Medical transcriptionists convert audio recordings of physician dictation into written notes that can be integrated into electronic health records (EHRs). A reliable US-based medical transcription company would have a team of trained and experienced professionals on board that can provide documentation solutions for various specialties. With the incorporation of speech-to-text technology in healthcare, providers can dictate into the electronic health record (EHR) and get clinical notes in real-time, decreasing time spent on documentation.

Despite the advances in voice recognition, human-based medical transcription services continue to play a critical role in the industry and improve healthcare communication.

Accurate and timely transcription of medical dictation: Medical transcriptionists can provide accurate transcripts of types of all types of medical records and medical documents including patients medical histories, examination reports, discharge summaries, chart notes, psychiatric evaluations, x-ray reports and more. They are well-versed in medical terminology and pharmaceutical aspects and also have superior typing and grammar skills. These skills enable them to deliver error-free transcripts. Review of machine-generated reports by medical transcriptionists also improves their accuracy. Service providers ensure that accurate transcripts are sent in quick turnaround time so that physicians and other healthcare providers have up-to-date information about their patient’s past and current conditions.

Improved collaboration among healthcare professionals: Interprofessional communication and collaboration plays a key role in healthcare. Complete, accurate and timely patient records enhance inter-physician communication and enable them to develop a proper treatment plan for the patient. Studies have shown that such collaboration can improve patient outcomes by reducing preventable adverse drug reactions and other medical errors^,optimizing medication dosages, and decreasing morbidity and mortality rates. A Robert Wood Johnson Foundation study of 20 hospitals found that by improving interprofessional collaboration between nurses and physicians, one hospital reduced its fall rate in half, cut average length-of-stay by 0.6 days, increased annualized bed turn by 20 percent, and increased discharges before noon by 20 percent.

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Gives physicians more time to focus on patients: Medical transcription outsourcing also streamlines workflows and frees up physicians’ time to focus on their patients. While EHRs can help reduce medical errors, when not used well they can strain the doctor-patient relationship. Time spent on the computer during the consultation takes away from the physician’s face time with the patient. With experts handling their EHR documentation tasks, healthcare providers can dedicate more time to patient care.

Reduces physician burnout: While the goal of EHRs is to make paperwork easier, a study by researchers from the University of New Mexico (UNM) that covered 282 clinicians reported that EHRs contribute to approximately 40 percent of clinician stress. The respondents appreciated the ability to access and update the EHR at their convenience, but expressed their dissatisfaction about how it led to after-hours EHR time. Using medical transcription services can help busy physicians save time and labor and ensure accurate and timely records of patient interaction and care.

HIPAA compliance: Reliable service providers will also help physicians ensure that reports comply with medico-legal concerns, policies and procedures. Ensuring the security, privacy, and protection of patients’ healthcare data is critical for all healthcare organizations and personnel. HIPAA compliant medical transcription companies understand the importance of maintaining patient confidentiality have various measures in place for this. This includes ensuring that protected health information (PHI) is stored on secure systems and protected with specific controls such as strong passwords, email encryption, intrusion prevention software, locking down USB ports, etc.

Customized solutions: Medical transcriptionists can provide quality reports in customized turnaround time ranging from 12-24 hours, which can help ease physicians’ workload to a large extent and importantly, avoid backlog. As they are knowledgeable about medical terminology, anatomy, and physiology, they can provide accurate documentation solutions for all medical specialists according to their requirements, even meeting sudden demands. Transcriptionists’ ability to understand the healthcare professional’s audio recording, correctly transcribe the information, and identify inaccuracies in the transcript is critical to preventing ineffective or even damaging treatment.

Quality control: Established medical transcription companies have stringent quality control measures in place to ensure the transcribed reports meet the highest standards of accuracy and consistency. The QA process includes three levels of checks by editors, medical editors and proofreaders for 99% accuracy. All transcriptions are also done using software such as the American Drug Index, Stedman’s Electronic Medical Dictionary and the complete range of Stedman’s books.

Quality, up to date information for patients: The regulations under the Health Insurance Portability and Accountability Act (HIPAA) provide individuals with the ability to access and obtain a copy of their health information. According to new federal rules, health care organizations must give patients unfettered access to their full health records in digital format. Patient access to medical records can enhance patient engagement and also improve patient safety and care quality. Competent medical transcription service providers can help ensure data quality in the EHR.

Flexibility: Partnering with a flexible transcription company is very important. Reliable service providers offer flexible dictation options such as digital recording and dictation to a toll-free number. They can also meet physicians’ stringent submission deadlines when needed. They are also in contact with the physician always so that they can make any changes to the records as required.

Cost-effective: Outsourcing healthcare transcription is also more cost-effective than doing it in-house. It can save the overall costs of equipment and infrastructure, salary, HR, benefits, and maintenance and training. With a dedicated third-party transcription provider, the benefits and savings far outweigh the risks and costs.

Human-based medical transcription services are a reliable option to maintain quality EHR documentation that improves collaboration among healthcare providers as well as among providers and patients. When care teams can collaborate easily and effectively, it can streamline workflows and drive improved patient outcomes. With the high levels of accuracy, consistency and timeliness that they provide, human-based transcription services allow health care professionals to focus their efforts on improving patient care.

We have extensive experience providing customized medical transcription services for individual physicians, clinics, and hospitals to medical management companies across the US. Our services are available for all major medical specialties and sub-specialties.

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What is the Role of Medical Transcription in Healthcare?

27-March-2023 Rajeev Rajagopal Medical Transcription

Medical Transcription in Healthcare

The role of medical transcription is rising in significance owing to the increased demand for healthcare services and consequent increase in documentation requirements. Medical transcription in healthcare focuses on ensuring reliable, accurate, and timely documentation of clinicians’ notes and dictations. Most physicians rely on professional medical transcription services for maintaining error-free medical records, and free up more time to focus on patient care.

Key Challenges of Medical Transcription in Healthcare:

Many physicians consider clinical documentation a burdensome task that reduces face time with patients, and drives burnout. Published in 2021, a study titled Analysis of Electronic Health Record Use and Clinical Productivity and Their Association with Physician Turnover evaluated data from 314 medical professionals in an effort to determine whether medical records and physician departure or resignations are related. They found that clinicians could spend up to 5.8 hours managing medical records for every eight hours of scheduled patient time.

Another cross-sectional study titled Medical Documentation Burden Among US Office-Based Physicians in 2019: A National Study published in 2022, analyzed office-based physician responses to the 2019 National Electronic Health Records Survey. The 1524 respondents represented 301 603 physicians nationwide. This study also revealed that documentation burdens US physicians. Most respondents indicated that documentation takes time from patient care.

While accurate medical records are essential for diagnosis and treatment, the electronic medical documentation workflow is burdened by bureaucratic requirements. Rigid documentation structures and strict administrative standards are making things extremely difficult for physicians. These challenges highlight the importance of clinical transcription in hospitals, where skilled medical transcriptionists can help ease documentation burdens, improve accuracy, and give physicians more time to focus on patient care.

Medical Transcription in Healthcare

How Medical Transcription Services Help

Medical transcriptionists are highly trained professionals who undergo extensive training to ensure they can perform their jobs well. They ensure that medical dictations or recordings are transcribed into accurate and reliable medical records while also abiding by HIPAA regulations. By delivering proper and timely information on a patient’s condition to physicians and other healthcare workers, transcription services support provider collaboration and quality care. By documenting, organizing, and capturing patient data, transcription services offer a simplified method for recording patient care. In addition to supporting patient treatment, these records have legal value as they can be cited in insurance and medical malpractice lawsuits.

Transcription services offer several benefits:

Improved Accuracy: When it comes to medical records, accuracy is crucial. Documentation errors can lead to erroneous diagnosis, ineffective therapies, and put a patient’s life in jeopardy. With a 99%+ accuracy rate guaranteed by its staff of human editors and cutting-edge speech-to-text technology, medical transcription services enhance care delivery and patient safety.

Timely Charting: Time is critical in healthcare settings. Patient treatment may be greatly impacted by the speed at which medical records are transcribed and made available. Healthcare providers gain rapid transcribing turnaround times. This makes it possible for physicians to quickly obtain the information they require, resulting in quicker and more efficient patient treatment.

Simplified Procedures: The administrative workload that healthcare providers face is always growing. By automating the process of turning spoken words into written text, transcription helps optimize workflows. This lessens the need for manual data input, reduces risk of clinician burnout, and frees up providers to devote their attention to patient care rather than administrative work.

Improved Information Security: The healthcare industry places a high value on confidentiality, and any data breach can have dire consequences. Sensitive patient data is always protected thanks to secure technology in transcription companies, which helps healthcare practitioners abide by laws like HITECH and HIPAA.

Multidisciplinary Communication: Integrative patient care requires efficient communication across various departments and expertise. Transcribing reports allows clinicians to quickly share them with involved parties such as nurses, specialists, and primary care doctors. This guarantees that all providers are in agreement with regards to a patient’s care plan.

Medical transcription services are integral to the efficient functioning of the healthcare system. They enhance accuracy and consistency in patient records, save time for healthcare providers, improve patient care, support EHR integration, and ensure compliance with legal standards. Proper formatting of medical documentation is crucial for clarity, consistency, and ease of use, and these services ensure that all records are accurately structured according to industry standards and provider preferences.

By outsourcing medical transcription for healthcare facilities, healthcare organizations can focus on providing high-quality patient care while benefiting from streamlined operations and improved documentation practices. Reliable providers have multilevel transcription quality assurance practices in place that ensure that all documentation meets the highest standards of accuracy and compliance, reinforcing the critical role of transcription in today’s medical environment.

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Common Medical Charting Errors to Watch Out for

23-March-2023 MTS TEAM Medical Transcription Company

Medical Charting Errors

Valid, accurate, complete, trustworthy, and timely electronic medical records improve the utility of clinical documentation, and enhance communication between healthcare providers. One of healthcare’s worst nightmares is wrong information in the medical record. As a medical transcription company in the U.S., we are focused on converting physician dictation to accurate text. However, healthcare providers can make mistakes that compromise the integrity of the medical records and patient safety. Multiple studies have highlighted the seriousness of the problem:

A John Hopkin’s study suggested that medical errors account for more than 250,000 deaths per year in the U.S.
According to a poll by the Kaiser Family Foundation, 21 percent of respondents reported that they or a family member noticed an error in their EHR.
In a survey study of patients published in in 2020, 1 in 5 patients who read a note reported finding a mistake and 40% perceived the mistake as serious.

Even small errors or omissions in a patient’s medical record can result in serious patient injuries and harm as well as have legal consequences for the provider.

Common Medical Charting Errors

Let’s take a look at the common medical charting errors, why they occur, and how to avoid them.

Incorrect medical history: Wrong medical information in patient records is a common error. While some errors are harmless, others can be worrying or fatal. CNBC references a leading health IT company estimates that about 70 percent of records have wrong information. The report was on a young student who found that her medical record stated that she had two children when she had never been pregnant! Another study published on JAMA Open Network said that a patient who mentioned chest pain, tightness, and palpitations found all these marked as negative in the chart. In other cases, the provider did not document the most important reason for the visit.

The history is the key component of patient assessment and considered the most important part of the patient-physician interaction. Improving patient history taking practices is crucial to obtain the correct information and drive patient collaboration and trust.

Inaccurate medication instructions: The five “rights” of medication administration are: right patient, right medication, right time, right dose, and right route. Inaccurate documentation of the patient’s symptoms, diagnosis, or treatment can lead to inaccurate medication instructions. Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors.

Drug administration prevention strategies include standardized communication in electronic health records (EHRs), standardized product labeling, and drug information resources to alert “look alike, sound alike” drug names and using the correct expression of numeric doses.

Documenting orders in the wrong chart: Factors that lead to orders being wrongly documented in the chart include patient misidentification during registration, difficulty in locating the patient’s EHR, existing duplicate medical records, and typos. Patient misidentification or patient ID errors are among the most common errors in health care. A 2018 Pew Charitable Trusts report found that one out of every five patients may not be completely matched to their medical records.

Patient ID errors can lead to patients getting the wrong treatment, which can have grave consequences. The issue can be avoided with the right identification analyses, workflows, and safeguards in place. Healthcare organizations should identify the root causes of patient misidentification, understand the reasons or contributing factors behind noncompliance, and take steps to correct the problem. Experts recommend having a reliable patient identification system throughout the states.

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Use of inappropriate abbreviations: For physicians and nurses, using abbreviations can be a real time-saver during documentation. Abbreviations facilitate quick charting, but providers and their patient are at risk if it’s not done correctly. Chances of misinterpretation are high with medical abbreviations. For instance, if a nurse misinterprets “mg” as “milligram”, when it actually means “microgram”, it can lead to serious problems for the patient. Further, trying to figure out what the correct interpretation can waste precious time.

There are many error-prone abbreviations in healthcare. The ISMP National Medication Errors Reporting Program (ISMP MERP) allows subscribing healthcare institutions to report and track medication errors in a standard format. The program has published a list of abbreviations, symbols, and dose designations that have misinterpreted and involved in harmful or potentially harmful medication errors. Best practice is to avoid unnecessary abbreviations and use only abbreviations you are certain about and avoid those you don’t know.

Not documenting important information: When a healthcare professional does not document important information about a patient’s condition or treatment, it can have serious consequences, unless the problem is discovered and corrected in a timely manner. For instance, the treatment history should include:
- Chief complaints
- History of illness
- Vital signs
- Physical examination
- Surgical history
- Obstetric history
- Medical allergies
- Family history
- Immunization history
- Habits include diet, alcohol intake, exercise, drug use/abuse, smoking, etc.
- Developmental history
Leaving out any of these elements can result in incomplete information in the medical record. Likewise, a physician may forget to document the results of a laboratory test. Incomplete documentation errors in healthcare can affect care. To prevent this issue, the Medicare Claims Processing Manual says “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

Transcription errors: Transcription mistakes can occur with speech recognition (SR) software. Speech recognition may reduce the clinical documentation burden, but one study found an error rate of more than 7% in SR–generated clinical documents. Researchers have found potentially significant error rates in software-transcribed emergency medicine and radiology notes, according to a study published by the Patient Safety Network (PSNet). That’s why manual editing and review of machine-generated documents is essential.

Careless use of copy-paste: Another charting mistake relates to the use of the EHR system’s copy-paste function. Many physicians find EHR data entry cumbersome and time-consuming, and try to save time by copy-pasting patient information from previous encounters into the current encounter’s notes.

Medical documentation is an essential part of patient. Errors in documentation can lead to leading to patient injury, including delays in treatment, misdiagnosis, and even death. Healthcare providers to be aware of these errors and take steps to avoid them. Partnering with a professional medical transcription company is an ideal way to reduce the risk of documentation mistakes and promote clear, legible, compliant and timely charting to support superior patient care.

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5 Ways Voice Recognition is Improving Healthcare

20-March-2023 Julie Clements Medical Transcription Outsourcing

Voice Recognition

Voice or speech recognition technology (SRT) uses artificial intelligences (AI) to interpret spoken audio and convert the spoken words into text on a computer screen. Voice recognition is making waves in many fields and its applications range from performing initial job interviews, controlling digital devices and enabling hand-free technology to breaking down communication barriers for the visually and hearing impaired. Speech recognition supported by medical transcription services is now a widely accepted way to create error-free medical records.

Today, SRT is enhancing the delivery of healthcare in many ways:

Reduces the need for written documentation: SRT technology can be used as a tool for communication between health care providers and patients. SRT allows patients and their families to communicate clearly face-to-face with healthcare providers. Patients who have difficulty using their hands due to illness or injury and cannot send mails or messages to their healthcare provider can use SRT to communicate instead. Other patients may have problems reading or understanding prescriptions and other information presented to them on paper. Voice recognition makes communication easier for these patients.
Improves care and healthcare staff efficiency: In addition to being useful for patients and residents, voice interactive technology is useful to senior and post-acute care staff, notes a HealthTech article. Staff can use it to triage patient or resident needs and medication requests, instead of physically going into a room to communicate. Overall, voice recognition can reduce the challenges of information exchange and data collection and free up healthcare staff to focus on core tasks and improve efficiency.
Helps with language barriers: Leading voice recognition software supports automatic real-time translation for multiple languages, and transcription and translation for 60 languages. This makes SRT quite usefully for patients who cannot communicate traditionally.
Captures the patient’s voice: Voice data can provide valuable, valid and reliable evidence about how the patient is doing. Voice notes captured during consultations is an important source of voice data in healthcare. These recordings of patient voice in healthcare can be organized and used for future medical references, or to know the reasons behind positive and negative feedback. According to a Forbes article published last year, “The patient’s voice will become a source of data not altogether different than blood pressure, temperature and other vital signs”.
Documentation: Voice recognition has transformed the way clinical documentation is created. Physicians just need to dictate their notes and the system will record and convert the spoken words into text. Let’s look into this in more detail.

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Voice Recognition and Medical Documentation

One of the most significant uses of speech recognition technology in the healthcare industry is the automation of the medical documentation process. Clinicians are using the technology to speed up the transcription of patient information. The technology converts words into a text in real time. Voice recognition software can transcribe encounters three times faster than manual typing into the EHR. Reports say that it can significantly reduce physician burnout and free up a couple of hours a day for a provider who sees twenty to thirty patients a day (healthcareitnews.com).

The latest AI scribes use voice recognition, machine learning, natural language processing, and other models to automate clinical documentation. For instance, DeepScribe works as follows:

listens in on a patient encounter via the provider’s cell microphone
creates a high quality recording
AI uses natural language processing to autonomously extract the medically relevant information from conversation
produces a complete medical note and integrates it directly into the relevant EHR fields

According to DeepScribe, with their AI-powered tool, clinicians no longer have to endure the burdens of medical documentation or even dictate during their encounter or after. The provider can just speak naturally during the encounter, and DeepScribe will take care of the rest.

Despite the advantages of voice recognition to automate clinical documentation, medical transcription outsourcing continues to be relevant. Certified medical transcriptionists listen to audio recordings of dictations by and transcribe those dictations to text to create medical reports. Moreover, as automated transcription has accuracy concerns, having the reports checked by a medical transcription service provider is essential.

Many providers are using a hybrid approach or combination of automated and manual methods, according to Dolbey. This involves filling some text fields or checking some boxes manually and using voice recognition to complete the rest of the documentation. It could also involve using speech recognition to draft the documentation and using medical transcription services to edit and improve its accuracy.

4 Best Practices to Maximize Efficiency in Dentistry Transcription

13-March-2023 MTS TEAM Medical Transcription

Dentistry Transcription

The health of the patients is the most crucial aspect of any medical practice, including dental practices. However, keeping track of and managing patient records is a challenge for many dental clinics. This might result in expensive errors such as misdiagnosing a condition or providing medication that may not be required. To streamline dental record keeping and increase office efficiency, dentists can use dentistry transcription services. Professional medical transcriptionists provide clear, accurate transcripts of the dentist’s audio recordings so that all details of the patient are always within reach.

Importance of Timely and Efficient Dental Transcription

When a patient visits you, you need to capture all information about his/her present and past medical conditions, medications that have been prescribed, reports, and tests. The best way to speed up this process is to have the patient interaction recorded and later transcribed by a professional transcriptionist. This record is an important part of the patient’s medical history that you can quickly access as and when necessary. Your billing and coding staff can use dental records that have been prepared systematically to speed up insurance claims processing and more easily obtain insurance reimbursement. Dental professionals can utilize the patient record as a reference for patient treatment, including warning indications that need to be investigated, with the help of accurate dentistry transcription. In the event of legal disputes, these records can be an invaluable asset. Therefore, accurate dental transcription is crucial for every dentist or dental office.

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If you are planning to have in-house staff do the transcription, here are 4 effective ways in which you can improve efficiency of your dentistry transcription. In fact, these are best practices that a medical transcription company follows to ensure optimum transcription solutions for dentists:

1. Use the right medical transcription software for dictation: The right software can help improve the efficiency of medical transcription.

Such software is specifically designed for dental practitioners to achieve the highest efficiency in dental and clinical documentation.
You can choose software that is compatible with your EHR, and it will enable you to keep your dictation document in sync with your EHR.
Medical transcription software comes with voice capture and speech recognition capabilities. So, the transcriptionist can more easily and accurately capture the dentist’s dictation.
The software supports a variety of audio and video file formats.
Other significant features available are medical spell checking and dictionaries.
Once the transcript is quality-checked and approved, the software can make the transcript available in the desired format. It can be synchronized to the dentist’s computer or handheld device, or sent for printing.

2. Use state-of-the-art cloud-based computing: This facilitates safe storage as well as access of data. Cloud technology ensures safety with document transfer and helps meet HIPAA compliance when sending, sharing or retrieving voice and data files over the Internet. Moreover, this technology is scalable in keeping with your changing demands. Transcription becomes simpler to manage and carry out, and this increases the efficiency of your dental transcription. Since the cloud provider offers the necessary resources, dental practices get valuable cost savings and excellent ROI.

3. Use artificial intelligence for efficiency and accuracy: AI or artificial intelligence is going to be increasingly used in all business sectors because it is the technology of the future. This technology comes with many advantages, and medical transcriptionists can produce more accurate and increased number of transcripts faster.

4. Take measures to improve your TAT: This can be achieved through using transcription productivity tools such as Word Auto-Correct and Macro features.

Apart from these, there are Word expander software such as Instant Text or Shorthand that can increase productivity considerably and speed up transcription turnaround time.
Use high-quality headphones: This will help hear audio sounds clearly, and understand them easily. It will also help avoid having to replay the audio again and again to figure out inaudible words.
Use a foot pedal to make work easier: You can have rewind, play/pause, and fast forward functions to improve efficiency and speed. Other functions you can have include slow down, jump, or next dictation among others.
Improve ergonomic features in your office: This helps avoid discomfort while working, and thereby improve efficiency and productivity.

One of the best ways to streamline dental transcription is by outsourcing to a professional transcription vendor. It is one of the quickest and most secure means of managing your patient records.

These transcription vendors have professional transcriptionists who are trained and are knowledgeable in dental terminologies, which enables them to produce error-free transcripts in a short period of time.
They also ensure high level of patient data confidentiality and with access to transcripts quickly, dentists and other related staffs can print or distribute medical documents to multiple destinations through the internet.

Reduce Charting Time with Dentistry Transcription Service

Complete your documentation before the next patient encounter. Eliminate the need for charting after office hours.

For any dentist to provide the right care, it is important to have access to accurate patient records. Therefore it is vital for dental practices to invest in dentistry transcription services. With effective dentistry transcription, dental practices can stay organized and improve the quality of their services.

6 Ways Physicians can Improve Dictation Efficiency

09-March-2023 Julie Clements Medical Transcription

6 Ways Physicians can Improve Dictation Efficiency Clear, accurate and timely medical records are essential to support patient care. Physicians need to relay precise and accurate data to the other members of the patient’s care team. Dictated reports are usually sent to a third party for transcription. One problem that teams in US based medical transcription companies face is unintelligible reports due to poor dictation. Transcriptionists say that record quality and timeliness depend to a large extent on the quality of the audio recordings they receive from physicians. Let’s take a look at that factors that impact dictation quality and how physicians can improve dictation efficiency.

Reasons for Poor Dictation Quality

Physicians prefer dictation to taking notes when they are face-to-face with their patients. Dictating frees them to focus on each patient, allowing them to efficiently carry through and conclude each visit, and prepare to see the next patient. Dictation within the exam room reduces the time spent on recording care. However, there are many factors that can detract from dictation quality and make it challenging for medical transcription service providers to deliver accurate notes from the audio sent to them:

Workload: Busy physicians may dictate on the go or during their busy schedule. This can lead to them dictating too fast and inadvertently missing out critical information when documenting a procedure. Clarity is a major problem with a fast dictation.
Background noise: Physician dictation doesn’t always take place in a controlled environment. Physicians have a tendency to multitask. They may dictate while eating or chewing gum, or when they are driving or in a crowded room, which can all affect dictation quality. Even if they dictate in a hospital setting, noise created by patients, family members, or medical assistants can affect the dictation recording process.
Lack of organization: This is another key factor that can impact dictation quality. Not being organized when reporting a case can lead to something important being left out, especially if there are interruptions during the dictation process. In addition to procedural information, dictators who lack consistency can leave out even patient demographic information.
Speech patterns: Mumbling can happen when clinicians dictate the same procedure several times during the day. In fact, mumbling is one of the most common dictation problems for medical transcriptionists. Speech patterns can also be impacted when the clinician is tired, and result in whispering.
Heavy accents: Heavy accents may a problem when it comes to medical dictation. Processing the speech of people with accents can be a challenge for both human transcriptionists and speech recognition software.

Dictation accuracy and sound quality are crucial because decisions about treatment and ongoing care are based on information in the chart. Poor dictation habits and bad audio can:

affect quality of patient care and safety
result in incomplete coding due to reports with blanks of missing information
cause delays in care
lead to delayed reimbursement
impact transcription accuracy and turnaround time

A reliable medical transcription company will not fill in a report that is incomplete. Instead, they will send it back to the physician for clarification. This causes delays throughout the entire system and significantly increases the time needed to create a complete and accurate report.

Six Best Practices to Improve Clinician Dictation

The correct workflow and practices can significantly reduce the time that clinicians spend on dictation. Here are 6 effective ways to avoid dictation-related problems:

Physician education: Industry experts say that education is the best way to improve dictation practices (radiologytoday.net). Communicating the importance of high-quality dictation can influence physician by showing them how it supports patient care, billing, and even legally. Beginning a dictation session with proper patient identification is a helpful practice. Informing radiologists about the importance of entering the correct numbers at the beginning of a dictation session will ensure that the correct work type and patient demographics are used. Correct documentation will eliminate the need for clarifications and improve radiology transcription turnaround time.
Dictating in the presence of the patient: Dictating in front of the patient is recommended. This will not involve any extra time. It will also improve the accuracy of the history and physical as you can ask for clarifications. Patients can get a better understanding of their condition and treatment recommendations. Improving the quality of your records can improved reimbursement, and provide malpractice protection and patient care. Patient-present dictation also increases patient satisfaction as the physician is spending more time with the patient.
Organize your thoughts: To improve dictating, consider making brief notes or jotting down keywords in advance. This will help you organize your thoughts during dictation and help you include the right information in your narrative.
Location is important: As we have seen, a noisy dictation environment is a common problem. Even in the hospital, quality is a major concern for dictation done at nurses’ stations where background noise can be overwhelming. As far as possible, dictate in a quiet setting.
Use speech-to-text: With speech recognition (SR) software, physicians can dictate and immediately review the results of the charting session. The technology offers the best of both worlds – physicians can continue to dictate while avoid typing and quickly document medical history, symptoms, treatment plans, and other observations. Studies suggest that SR can improve overall process efficiency when used for dictation tasks such as reporting radiology or pathology results. Accuracy of machine-generated transcripts can be improved by getting them checked by an experienced medical transcriptionist.
State numbers and homophones clearly: Numbers and other numerical concepts appear throughout clinical notes and signify the value reported to indicate the function of cells, glands, hormones or organs in the body. When dictating numbers, use the appropriate form. As some digits can be easily confused when dictated, for e.g., 15 and 50, spell them out. This is especially important for medication dosages, where errors can lead to the wrong treatment. Repeat or spell out dosages precisely. Likewise, if not handled properly, homophones or same-sounding words can make a report inaccurate and useless. If you use ‘their’ and ‘there’, spell them out.

Dictation quality is crucial when it comes to documentation quality. Established medical transcription companies guarantee an accuracy level of 99 percent and custom turnaround time with good quality dictation.

How to Ensure Your Documentation Meets the MEAT Criteria

02-March-2023 MTS TEAM Medical Transcription

How to Ensure Your Documentation Meets the MEAT Criteria According to ICD Coding Guidelines, all conditions co-existing at the time of the encounter that require or affect patient care and management must be clearly documented and assigned a diagnosis code. Each diagnosis must be documented clearly and precisely by the physician based on the clinical documentation from the face-to-face patient encounter. Outsourcing medical transcription ensures that physician-dictated progress notes are converted into text format in an accurate and timely manner. MEAT represents four aspects and is a reliable way to ensure proper documentation for risk adjustment and coding.

Medical transcription services ensure appropriately documented medical records, which is an important element to support high quality care by:

Allowing healthcare professionals to evaluate and plan the patient’s treatment and monitor care over time
Promoting communication among providers and supporting continuity of care
Facilitating accurate and timely claims review and payment
Supporting appropriate utilization review and quality of care evaluations
Enabling collection of data for research and education

Importantly, medical transcriptionists provide complete and accurate clinical documentation that shows evaluation and treatment for all conditions assessed at the time of the encounter and supports MEAT.

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What is MEAT?

M.E.A.T. expands to: Monitor, Evaluate, Assess/Address, and Treatment. Documentation that meets the MEAT criteria helps providers establish the presence of a diagnosis during an encounter and ensure proper documentation for risk adjustment and Hierarchical Condition Category (HCC) processes.

Providers must thoroughly document all chronic disease processes and manifestations in the patient’s medical record for proper Risk Adjustment and HCC coding mandated by CMS. Many chronic conditions are HCCs. This coding model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and other aspects. MEAT helps coding professionals identify reportable conditions.

MEAT Criteria to Establish Presence of a Diagnosis

Simply listing diagnoses in progress notes is not acceptable or valid per official coding guidelines, and does not meet the requirement of an assessment and plan. To support an HCC, documentation must support the presence of the disease/condition, and also include the clinical provider’s assessment and/or plan for management of the disease/condition. That’s what makes MEAT relevant.

Meeting MEAT criteria means properly documenting all conditions evaluated and considered during treatment for every face-to-face visit. A well-documented progress note would include the following:

the history of present illness, physical exam
the medical decision-making process
documentation of each diagnosis in the assessment and care plan

By properly documenting each diagnosis in the assessment and plan, providers can demonstrate that they are Monitoring, Evaluating, Assessing and Treating the condition. To comply with MEAT criteria, the provider must document the following aspects:

Monitor: Document all signs, symptoms, disease progression/regression, disease regression, and ongoing monitoring of the chronic condition (ordering of tests and referencing labs/other tests)
Evaluate: Document the present state of the condition, physical exam finding, test results, medication effectiveness and response to treatment (physical exam findings).
Assess/Address: Document the discussion of chronic condition, review of records, counseling, acknowledging, documenting status/level of condition, how the chronic condition will be evaluated, and ordering of further tests.
Treatment: Document care being provided for the condition, prescribing or continuation of medications, referral to specialist, ordering diagnostic tests, therapeutic services, other modalities, and plan for managing the chronic condition.

Here are some best practices from AHIMA to ensure high-quality documentation to support HCC reporting:

All cause-and-effect relationships should be documented.
All diagnoses that receive care and management during the encounter should be reported.
Complications or manifestations of a disease process should be clearly linked.
All current diagnoses should be documented as part of the current medical decision-making process and included in the note for every visit.
Conditions that are no longer active and/or not being treated must not be reported. This includes problem list diagnoses that have been resolved.
Providers should ensure that all diagnostic codes for the encounter are captured in the electronic health record (EHR) and submitted in the claim.

Medical Transcription Outsourcing supports Accurate and Comprehensive Documentation

Outsourcing medical transcription is an ideal way to ensure EHR-integrated progress notes that are concise, legible, organized, and useful. Good progress notes or SOAP (Subjective, Objective, Assessment, Plan) notes tell the patient’s story. Progress notes integrate various aspects of the patient’s treatment and call attention to important issues relating to care and emphasize patient care and safety. These notes provide information related to medical decision-making, patient-provider communication, critical thinking, billing and coding and medico-legal requirements for documentation. Medical transcription services can go a long way in helping providers in their efforts to thoroughly document evaluation and treatment for all valid diagnosis to meet the MEAT criteria.

Including one or more of the M-E-A-T details at a face-to-face visit for each condition that requires or affects patient care treatment or management will put you on the path to success in capturing risk

Most chronic conditions are assigned to an HCC.

To support an HCC, documentation must support the presence of the disease/condition, and also include the clinical provider’s assessment and/or plan for management of the disease/condition.

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Medical Documentation of Burn Injuries

27-February-2023 Julie Clements Medical Transcription

Medical Documentation of Burn Injuries For successful treatment of burns, adequate documentation is a major concern. Up-to-date burn injury documentation brings more challenges and requirements for practices. Emergency departments can consider outsourcing medical transcription to get accurate reports of the treatment recordings.

Studies have highlighted that although traditional paper-based documentation is still used in practices, it no longer meets modern requirements. Instead, proper documentation is ensured by electronic documentation systems.

Burn care mainly focuses on the six “Cs” such as – clothing, cooling, cleaning, chemoprophylaxis, covering and comforting. Factors that guide the evaluation and management of burns that leads to accurate documentation include

The type of burn (thermal, chemical, electrical or radiation)
The extent of the burn usually expressed as %TBSA, and
The depth of the burn

Along with documenting an appropriate E/M encounter, other factors to be documented for patients with burns are – location, size relative to total body surface area (TBSA), whether dressings or debridement were performed and by whom, specific patient characteristics such as the age of the patient, any other medical or health problems, any associated injuries, and more.

Anatomical locations documented should include laterality, left or right, and the specific part of the body involved. The depth of burns has to be documented as first degree, partial thickness, or full thickness.

Burn Documentation Features

Experts have clearly defined the required medical details for burn documentation.

Advanced burn documentation should include:

Medical history and general status of the patient with all its features
Recent and frequent photographic documentation to evaluate changes in the wound
Wound assessment with all its features
Course of healing
Documentation of therapeutic measures and their effects
Results of follow-ups
Traceability and verification of authors

Proper TBSA Estimation

Accurate burn size assessment is crucial. Determining burn severity relies on the burned surface area, depth of burn and the involved body area. Many methods are currently available to estimate the percentage of total body surface area burned. TBSA or total body surface area affected by a burn can be estimated using Lund Browder Chart, Rule of Palms or Rule of Nines.

Lund Browder Chart

“Lund Browder Chart” helps to improve the calculation of body proportions. This is the most accurate and widely used chart to calculate total body surface area affected by a burn injury. It helps evaluate the burned body surface area, by showing the boundaries of specific body regions. An adapted planimeter is used for the calculation.

Rule of Nines

This is another clinically efficient and accurate method to calculate the total body surface area of a burn. This estimation method provides an idea of how much of your total body’s surface area a burn takes up. Treatment can be chosen based on the size and intensity of the burn injury. Emergency department physicians use this estimation method the most.

Rule of Palms

It is another popular way to estimate the size of a burn. Physiopedia explains that the palm of the person who is burned is about 1% of the body. In this method, the patient’s palm is used to measure the body surface area burned. When a quick estimate is required, the percentage body surface area will be the number of the patient’s own palm it would take to cover their injury. It is important to use the patient’s palm and not the provider’s palm.

Choosing a Perfect Documentation System

Even though critical care medical transcription services can do a lot in properly documenting burns in EHR, it is crucial for providers to use a relatively comprehensive documentation system to ensure quality patient care.

Advanced documentation systems will cover many datasets including ethology of burns, burn depth and size over time, surgical steps, first aid measures, preceding clinical treatment, condition of the patient on admission, former illnesses, any additional injuries, healing progress and outcome, complications if any, image documentation, and more.

Electronic documentation systems have proven to offer many qualitative and quantitative advantages such as –

enhanced documentation quality
reduced documentation errors
faster availability and access to the collected data
direct exchange of information
creation of new medical knowledge

BurnCase 3D is a standardized documentation system that provides a library of 3D models to support and enhance the documentation and diagnosis of human burn injuries. 3D models created can be adapted to sex, age, height, and weight. This system enables full documentation of the entire treatment process from initial assessment to the outcome. Users can transfer burn wounds from photos to the 3D model. The 3D models created can be moved, rotated, and scaled for better evaluation.

Dos and Don’ts of Maintaining Good Clinical Records

23-February-2023 Rajeev Rajagopal Medical Transcription Outsourcing

Dos and Don’ts of Maintaining Good Clinical Records Well-maintained clinical records are critical for practices to deliver quality healthcare, to maintain continuity of care, and to share information among different healthcare providers. Medical records must be accurate, and written in a professional manner. Records should also include diverse components including history, patient examination, differential diagnosis, treatment, follow-up, and progress.

All the entries in the record must be legible, complete, timed, and should have a dated signature. For error-free documentation, it is better to make entries as soon as possible after the event before the relevant staff member goes off duty. Any delays should also be documented, including the time of the event and reasons for the delay. Physicians rely on medical transcription outsourcing to maintain a permanent account of a patient’s medical history and other care details.

Clinical Documentation: Dos and Don’ts

Poor quality documentation could result in adverse consequences for the physician as well as the patient such as, it can mislead healthcare professionals and patients, lead to wrong medical decisions, increase medico-legal issues, and even compromise patient care. Keeping quality documentation safe is also critical. While partnering with a HIPAA-compliant medical transcription company, practices must ensure the privacy and security of patient data to meet HIPAA requirements.