2023 HIPAA Compliance Checklist for Small Medical Practices

13-February-2023 Rajeev Rajagopal HIPAA Compliance, Medical Transcription

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 be used to identify an individual and that was created, used, or disclosed in the course of providing diagnosis, treatment, and other healthcare services. HIPAA non-compliance can result in heavy civil and criminal penalties. Covered entities and Business Associates like medical transcription service providers need to adopt measures for full compliance with the law to protect PHI and stay up to date with any changes.  In 2023, there are new HIPAA regulations that will impact small medical practices.

HIPAA Updates in 2023

In 2023, the responsibility of healthcare organizations to respond to requests is better defined as well as verifying the identity of parties requesting PHI and adequately handling data with third parties. Here are the key HIPAA Privacy Rule changes in 2023 that medical practices need to know about:

  • Changes to how patients access their health data: Patients can inspect their PHI in person and take notes or capture images of their PHI. The maximum response time to provide access to PHI has been reduced to 15 days (from 30 days).
  • Form and format for individuals’ PHI requests: The PHI access reform clarifies the form and format required for responding to individuals’ requests for their PHI.
  • Changes to how practices inform patients of their rights: Patient rights to access data are now more clearly defined. Covered entities are required to let clients know how they can access their health data and also that they can get a complete copy of their health information (instead a summary).
  • Sharing of PHI in an EHR:   The HIPAA update also creates a pathway for individuals to direct the sharing of their PHI in an EHR among covered healthcare providers and health plans. Covered health care providers and health plans are required to submit an individual’s access request to another health care provider and to receive back the requested electronic copies of the individual’s PHI in the EHR. Covered entities are also required to respond to certain records requests they receive from other covered healthcare providers and health plans when so directed by individuals who are exercising their HIPAA right to access their own PHI.
  • Transmission of PHI to electronic copies in an EHR: When an individual directs the PHI to be transmitted to a third party, the law limits PHI to electronic copies. This is intended to reduce the burden of PHI transmission as paper documents.
  • Provision of fee schedules: Covered entities are required to post estimated fee schedules on their websites and provide estimates of the fees to individual clients.
  • Exception to “Minimum Necessary” Standard: An exception to the “Minimum Necessary” standard has been created to accommodate individual-level care coordination and case management uses and disclosures.

Other updates include: specifying when electronic PHI must be provided to an individual at no charge; modifying the permissible fee structure for responding to requests to direct records to a third party, and requiring covered entities to post estimated fee schedules on their website for health information access and disclosures.

Implications of 2023 HIPAA Updates for Medical Practices

To stay compliant, medical practices need to pay attention to the following:

  • Convergence of data privacy and HIPAA security: With the emergence of electronic PHI or ePHI, security has become almost synonymous with privacy. Practices should have robust security solutions to protect PHI in the EHR as well as proper procedures in place for handling patient rights and data with third parties.
  • Focus on Staff training: Train security issues relevant to your practice, including the latest changes. Implement ongoing HIPAA compliance training for your entire workforce on security and compliance matters. All employees must be trained on steps to safeguard against threats. They must be able to recognize the signs of a phishing attack and correctly report any incident. Set up a system to track any security incidents and create documentation to deal with such incidents.  Additionally, make sure to that your business associates are knowledgeable about security policies and HIPAA compliant.
  • Conduct HIPAA risk assessments: HIPAA requires covered entities to conduct an “accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI”.  Make sure to conduct a HIPAA privacy risk assessment which takes account of risks to the confidentiality, integrity, and availability of non-electronic PHI, as well as individuals´ access rights (to their PHI), Business Associate Agreements, and other Organizational Requirements of HIPAA. Conduct periodic evaluations of security preparedness both internally and externally. Today, many facilities are utilizing compliance automation software to manage their risk assessment processes.
  • Implement cybersecurity best practices: Global healthcare cyberattacks increased by 74% in 2022, according to an article in HIPAA Journal. The healthcare industry experienced the highest percentage increase in weekly cyberattacks among all industries, with an average of 1,463 attacks per week. A 2021 report from IBM Security and Ponemon Institute found that healthcare data breaches cost on average $9.23 million per incident. Practices need to increase investment in cybersecurity and implement recognized best practices and methodologies.
  • Create effective response procedures: Create a plan for emergencies that may compromise ePHI. HIPAA requires covered entities must develop a data backup plan, a disaster recovery plan, and an emergency mode operation plan, among other administrative safeguards. The plan should include a way to continue critical business processes to protect the security of ePHI during an emergency.

With latest HIPAA updates, medical practices also have to be prepared to handle requests for information in a timely manner. Partnering with a HIPAA-complaint medical transcription company can help them meet clients’ record requests within the 15-day period. On their part, medical transcription companies will need to evaluate their security best practices to ensure HIPAA compliance when handling ePHI.

Modules of a Good Electronic Health Record

09-February-2023 Rajeev Rajagopal EHR Transcription

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 and treatment histories of patients into the electronic chart. EHRs are much more than a storehouse of clinical data. A good electronic health record would have components that drive better value-based care, interoperability, and much more.

How EHRs benefit Patients and Healthcare Providers

EHR systems offer many benefits for both patients and healthcare providers. The EHR improves communication between patients and physicians. Patients receive personalized notifications for appointments, follow-up visits and immunizations via the user-friendly patient portal. By scheduling appointment efficiently, EHRs cut down on patient wait times. Patients can view and track their medical information, prescriptions, and physician’s notes all in one place, which improves patient engagement and enables them to make faster decisions.

By proving a greater and more seamless flow of information, EHRs allow physicians to provide seamless care. Up-to-date information recorded in a patient’s EHR using medical transcription services can be easily shared with other providers and specialists involved the patient’s care. EHRs come equipped with many features to reduce errors and enhance care quality, such as e-prescriptions and decision-making support tools to prevent adverse events associated with drug allergies and negative drug interactions. With digital medical records, physicians can view lab results, provide consultations, and monitor patients remotely. EHRs also allow providers to manage billing and other administrative tasks.

Components of an EHR System 

To function effectively, EHRs are equipped with certain components, functionalities and features. In fact, EHR developers are constantly looking to upgrade the design and features of their systems. The essential components of an EHR system are as follows:

    • Patient demographics and health data: EHRs are designed to enable the identification of individual patients in clinical work flows:
      • Demographic information and patient identifiers -The patient demographic information that EHRs contain include age, gender, and ethnicity/race.  Demographic data are often used to match patient records across data sources. EHRs also contain patient identifiers which include the patient’s full name, date of birth, contact information such as address and phone numbers, name and contact information of close relatives, emergency contact details, and other personal information considered necessary for healthcare delivery.
      • Diagnoses: Diagnosis is often considered a key variable to evaluate a patient for inclusion in a registry, an essential tool for public health surveillance, research, and understanding rare diseases. EHRs problem lists are designed to provide clinicians with a brief summary of the patient’s active diagnoses and key health issues.
      • Genetic information: EHRs collect and protect genomic data. individual’s genetic data is used to predict a response to particular drug treatments.
      • Vital signs: Vital signs are an important facet of diagnosis and patient care. The Vitals tab in EHRs include all types of vitals measurements: temperature, pulse, respiration, blood pressure, and pulse oximetry, and much more. Vital signs are usually the first indication of a change in the patient’s health status and provide a baseline to determine the treatment plan’s effectiveness.
      • Medications: EHRs contain two types of medication information: medication history and prescribed medications (including route, dose, and day supply).
      • Chronic diseases and allergies: EHRs contain chronic disease data which can support more timely, actionable, and sustainable surveillance. Proper allergy documentation can enable clinical decisions to prevent adverse events.
      • Lab test results and radiology information: EHRs provide critical lab values and radiology data. The system allows clinicians to identify the necessary lab tests and order them electronically. By collecting and displaying lab results in meaningful ways, the EHR alerts clinicians to results that are outside normal ranges.
      • Immunization dates: The immunization record contains the complete timeline of the vaccines a patient received. Accurate immunization records are important for work, school enrollment, travel etc. The EHR Immunization records module makes it easier to document and track immunizations by showing when to schedule shots to protect against certain diseases.

 

  • E-Prescriptions: The electronic prescription component in the EHR allows physicians to prescribe medications more easily. E-prescribing allows providers to send patient prescriptions electronically to the pharmacy. E-prescribing has been found to reduce paperwork and the associated errors, increase efficiency, and save healthcare costs. Patients can collect the order when it is ready.
  • Laboratory interface: Lab interfaces allow providers to order lab tests directly from the EHR and seamlessly receive the results in the system. Today’s EHR vendors support a number of lab interfaces. Some offer results management in the form of viewing an electronic copy of the actual lab report results along with additional details, or visualizing the results in a table or graphical format. Some systems allow providers to review and share results with patients.
  • Billing: EHRs come with a billing functionality. Billing can be made more convenient by linking the EHR with billing software or integrating the account management function in the EHR system. Most systems provide a batch export of the physician’s daily encounters, and medical coders and billers can translate the information into accurate claims.
  • Appointment scheduling: This component should enable patient to view the physicians’ working schedule, choose the right specialist, and schedule an appointment. Ideally, the appointment scheduling system should allow the front office to see all encounters for all providers in the facility as well as understand the patient load for any given provider.
  • Clinical decision support: As explained above, EHRs make available vast amounts of patient data and other information in a single, digitally searchable, electronic location. By presenting information and images that can be searched, reviewed, and compared. EHRs support clinical decision making.
  • Electronic communication: EHRs allow clinics, laboratories, and pharmacies and physicians to share information including patient information and research results. For instance, providers need to request and share data for referrals. EHRs allow patient information to be securely shared with another healthcare professional. This can be done in via email or direct messaging. Physicians can analyze the information communicated by the EHR, evaluate chronic diseases, past illnesses, and genetic predispositions, and determine the best treatment for the patient.
  • Reporting: EHRs feature built-in reporting tools. They provide reports on patient data and billing and physician-specific activities. Customized reporting capabilities can promote efficient workflow and intelligent insights. When a provider opens a patient chart, the EHR will store each command as a reportable action. With the large types and amounts of data it stores, the EHR can provide reports on patient health history, treatment history, biometric data, symptoms, and lifestyle choices, and create a comprehensive summary of patients’ health status.
  • Population Health Management: The goal of Population Health Management (PHM) is to improve the health outcomes of a group of individuals by analyzing patient data in actionable patient records. PHM aims to develop new strategies to improve patient outcomes. The data gathered by the EHR system help providers ensure better patient outcomes and pursue Population Health Management. Advanced EHR systems support various PHM modules.

EHR systems offer multiple advantages including standardization of patient records in a legible format. They can increase patient safety, decrease medication errors, enhance and speed up communication, and improve the quality of patient care. However, to succeed with these goals, providers need to ensure accurate and timely EHR documentation. A medical transcription company that provides EHR transcriptions can ensure that clinical narratives are captured correctly and to meet providers’ specific requirements. This will allow providers to maintain error-free medical records and improve care delivery.

 

How Can You Improve Clinical Documentation?

06-February-2023 MTS TEAM Medical Transcription

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 information in the medical record is essential for the provision of continuous, high quality care. With the rising incidence of patients with chronic conditions and complexities of EHR data entry, many practitioners consider medical transcription outsourcing a reliable strategy to create proper medical records.

Today, there is an increased focus on clinical documentation improvement (CDI) to ensure accurate, quality, complete, and specific documentation that reflects severity of illness and care provided. Many providers are utilizing AI technology to create clinical documentation, reduce time spent on EHR data entry, facilitate effective patient interactions, and reduce the burden of after-hours clerical work. However, AI scribe service is here to stay, vetting by human transcriptionists is crucial to ensure accuracy.

Learn more about our medical transcription solutions and take the first step towards better patient care.

Contact us today

Why CDI is Vital for Patient Care

Proper patient care depends on efficient communication among healthcare providers. As an AHIMA article notes, the patient’s condition can change abruptly, and communicating and documenting changes and resulting responses is necessary to prevent “missteps” in care. The report explains that failure to document properly can lead to the following problems for the patient:

  • Being overcharged or not covered for treatment that may have been necessary
  • Being wrongly categorized as being less sick because aggregated diagnoses do not reflect severity of illness
  • A higher risk of developing complications of care since acuity of symptoms are not described
  • Face increased chance of readmission after discharge if the appropriate treatment plan was cut short or weekend follow-through lapsed due to short staffing.

Purposes of Clinical Documentation

The medical record is the most important means of communication between members of the patient’s healthcare team. As the American Health Information Management Association (AHIMA) explains, “Clinical documentation is at the core of every patient encounter. In order to be meaningful, the documentation must be clear, consistent, complete, precise, reliable, timely, and legible to accurately reflect the patient’s disease burden and scope of services provided”.

Good clinical documentation is important for many reasons:

  • Promotes continuity of care and communication among healthcare professionals involved in the patient’s care
  • Shows that proper care was given and documents the patient’s response to that care
  • Provides evidence for legal records
  • Creates patient registry functions to manage large populations better
  • Provides information for researchers conducting scientific studies
  • Helps create longitudinal patient records (LEPRs)
  • Enables medical coders to prepare and evaluate insurance claims
  • Paper or electronic documentation needs to be supported by imaging records such as X-rays, magnetic resonance imaging (MRIs) scans, electrocardiograms (EKGs), etc.

Strategies to Improve EHR Clinical Documentation

Strategies to Improve EHR Clinical Documentation and Save Physicians’ Time

  • Invest in EHR Training: It is important that organizations invest in training physicians and/or nurses who use the EHR system to improve efficiency and provider wellbeing. An article from the American Academy of Pediatrics lists the three steps in the EHR training process as:
  • Onboarding: This can be administrative in nature and include licensure, credentialing, creating a login account and customization of EHR interface or tools, or comprise pretests and exercises.
  • Classroom Training: This involves teaching providers how to navigate the EHR efficiently, learn inpatient and/or outpatient charting and flowsheets, and practice writing short, accurate notes designed to enhance clinical care, and customize workflow.
  • One-on-one Support: In this phase, a training team or an EHR-trained physician shows other providers how to use EHRs efficiently and avoid or decrease burnout. By working with groups, physicians can learn how to write clinical progress notes effectively using their EHR system.
  • Reduce Payer Documentation Requirements: A study published in 2018 reported that the length of the average patient note in an EHR was 700 words – more than double that in 2009. One of the reasons for this is payer documentation requirements. Clinicians and hospitals have to report an assortment of measures to different payers. The Patients over Paperwork initiative led by the U.S. Centers for Medicare and Medicaid Services (CMS) is aimed at reducing the administrative burden on providers. The initiative has made great progress in doing away with unnecessarily complex, outdated, or duplicative requirements that consume physicians’ time while doing little to improve quality of care.
  • Better Template Design: Improving EHR template design can save physician time spent on documentation. Many template designs focus on creating clinical notes to ensure efficiency at the point of care, but do not pay attention how the data is presented. Template design needs to be improved to allow physicians to spend less time on updating patient profiles and ordering exams, and more time with patients. Templates should also be designed for better presentation of data to patients, other providers, and staff for continuity of care.
  • Improve EHR Workflow: Experts who evaluated EHR implementations across several organizations said that removing unnecessary steps can improve workflows in the EHR by about 20%, on average – without any regulatory changes or technology innovation (www.hbr.org). Reducing the number of clicks that physicians need to perform should be done continually as it can increase provider satisfaction and reduce time for patients to be seen.
  • Take Advantage of Innovation: Huge volumes of unstructured data are inputted into EHRs on a daily basis. Advanced natural language processing (NLP) technology can provide great insights into the data and extract relevant information within the patient chart which can be used to improve the quality of care. Today, application programming interfaces (APIs) also support interoperability of EHR systems, allowing them to send or retrieve data to update a patient record.

Other Recommendations

The AAPC (American Academy of Professional Coders) defines CDI as “the process of reviewing medical record documentation for completeness and accuracy”. Clinical documentation review is performed by clinical documentation specialists who have both clinical and medical coding backgrounds. Here are some expert recommendations to improve clinical documentation:

  • Plan ahead and hire efficient CDI specialists.
  • Assess existing policies and procedures, including the current state of the facility’s CDI program.
  • Educate clinical documentation specialists, coders, and other clinical professionals before setting up the CDI program.
  • Review a sample of records to know where to focus efforts for documentation improvement and show how this will benefit the patient, practice, or population.
  • Review the medical record before the encounter to assess for issues and identify compliance opportunities
  • Have the CDI specialist review claims with targeted diagnosis codes before submission and determine if the documentation supports the codes. If not, the coder can reassign the codes.
  • Consider the changing health care operational environment and prepare for it.
  • CDI specialists should help physicians and coders work together to improve documentation.
  • Utilize technology.

Benefits of Clinical Documentation Improvement

CDI is beneficial for many reasons:

  • More meaningful patient information: An effective CDI program results in a more useful medical record and more meaningful patient information and data.
  • Improved patient care: Proper records can improve patient care in a healthcare facility. Review of documentation by the CDI specialist enhances communication between all providers involved in the patient’s care in a timely manner. This can reduce the length of stay for the patient and also help prevent avoidable readmissions.
  • Improved reimbursement: Payers often require additional documentation to support additional or more specific ICD codes to enhance hospital reimbursement and data collection. A CDI specialist can confirm patients have accurate diagnoses in the medical record by reviewing documentation and ensure comprehensive data for accurate reimbursement.
  • Timely reimbursements: When there are no errors in the documentation, it can prevent delays in claims processing.
  • Reduced denials: Improved clinical documentation can result in more accurate medical coding, which will reduce denials and improve the appeals process.
  • Validation of care quality: By ensuring quality clinical documentation and data, CDI can help healthcare professionals meet the demands to provide evidence of the quality of care.
  • Capture of accurate risk adjustment scores: Continuous capture of all chronic conditions on a yearly basis, accurate HCC coding, and identifying risk adjustment scores can lead to better patient treatments and outcomes as well as proper Medicare physician reimbursement.
  • Promotes compliance: Poor documentation leads to errors in claim submissions, which can attract audits and result in fines or return of money mistakenly collected from payers. When documentation is accurate and complete, it supports compliance with regulations.

Want to improve your clinical documentation? Discover how our expert medical transcription services can help you achieve accurate medical records.

Call us at 1-800-670-2809

When successfully implemented, a clinical documentation improvement program can ensure accurate and thorough medical record documentation. This will improve reporting quality, promote accurate reimbursements, and drive better patient outcomes. The widespread adoption of EHRs and technologies such as front-end speech recognition has made it easier to create clinical documentation. Partnering with a medical transcription company can help providers alleviate much of the burden associated with EHR data entry and ensure accurate documentation of medical history, physical exams, medication lists, and more.

How Medical Transcription Supports Healthcare [INFOGRAPHIC]

02-February-2023 Julie Clements Infographics

With the rising demand for healthcare services and consequent increase in documentation requirements, the role of medical transcription and transcriptionists is becoming more significant. Experienced providers of medical transcription services focus on ensuring reliable, accurate, and timely transcription of clinicians’ recordings and dictations. Error-free transcripts help physicians deliver quality, customized treatment, which is most important for favorable outcomes. Transcripts provide accurate, reliable and timely information on a patient’s condition. Transcription services are available for all medical specialties such as cardiology transcription, psychiatric transcription, neurology transcription, endocrinology transcription and so on. Professional medical transcriptionists ensure that medical dictations or recordings are transcribed into accurate medical records while also abiding by HIPAA rules.

 

Check out the infographic below

 

Medical Transcription

Read our Blog: 5 Key Roles Of Medical Transcription In Healthcare

What Are the Common Errors in Medical Documentation?

30-January-2023 Rajeev Rajagopal Medical Transcription

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 at great risk if this information is poorly recorded, not readable, or is delayed needlessly. High-quality care and patient safety are provided by good documentation. A trustworthy medical transcription company supports doctors by producing accurate medical records and ensuring that their documentation procedures adhere to high standards.

Want to Avoid Common Errors and Maintain Comprehensive Records?

Find Out How

Call 1-800-670-2809 today to talk to one of our Solutions Managers.

Four Main Reasons to Ensure Proper Medical Documentation

Here are four reasons why it’s crucial to accurately record patients’ medical information.

  • To communicate with other medical personnel: Documentation explains the what, why, and how of providing clinical care to patients. These data give other medical professionals access to patient histories, enabling them to continue offering each patient the best care possible. Along the continuum of treatment, from EM to HM and transitioning into the post-acute care setting, proper documentation also aids in patient navigation and coordination.
  • Minimizes exposure to risk management: Accurate and thorough documentation lowers risk as well as the likelihood of a malpractice claim being upheld. In the event of a claim, having a thorough record of the patient’s care and treatment allays any worries about culpability. When you are in the middle of a professional liability claim and several years have passed, it is doubtful that you would recall the specifics of a particular instance. In this circumstance, your documentation will be your go-to resource.
  • Documents, PQRS Measures and CMS Hospital Quality Indicators: Documentation records the value-based care measures that hospitals are increasingly being asked by the government to produce. These include MIPS metrics and Hospital Quality Indicators.
  • Provides proper reimbursement: A thorough medical record can speed up payment, lessen any “hassles” connected with claims processing, and guarantee proper reimbursement. It can also support efficient revenue cycle procedures.

Common Errors in Medical Records

Clinical documentation mistakes can result in inaccurate diagnoses and treatments, which can be risky or even fatal. Misspellings, inaccurate dates, switched numbers, and omitted information are examples of common medical documentation mistakes in the field. Also problematic is handwriting that is incomplete or illegible. In some circumstances, a mistake in one section of a document can render the entire document invalid.

  • Errors in transcription: For instance, a nurse might not accurately record a doctor’s orders. If the inaccurate information is not found and changed before being used, it may have devastating repercussions.
  • Misuse of abbreviations: Although acronyms are frequently used in medical documentation, improper use of these might result in mistakes. For instance, a patient can be given the incorrect amount of medication if the abbreviation “qd” (for “daily”) is misread as “qid” (four times per day).
  • Insufficient documentation: This happens when a medical provider doesn’t record all the details of a patient’s care. For instance, a doctor or nurse can neglect to record a patient’s laboratory test results or their vital signs. It might be challenging to deliver effective care when there are inaccuracies in the recording of healthcare.
  • Ignoring crucial information: This can occur when a physician or other medical expert neglects to record crucial details about a patient’s condition or course of treatment. If the omission is not noticed and remedied right away, it could have catastrophic repercussions.
  • Incorrect information entry: This mistake can happen when a medical professional enters inaccurate data in a patient’s chart. For instance, inaccurate birth date or prescriptions may be listed. This kind of mistake can be perplexing and may result in incorrect care.

Other Medical Errors

  • Inaccurate documentation: Doctors that are dissatisfied with their EHR configuration begin using their own templates. This could result in lost medical records and information. For instance, progress notes that end up in the section for procedure notes. When medical records such as lab or radiology reports are lost, doctors and nurses may have to make serious decisions about the patient’s care based on inaccurate information.
  • No primary complaint or past medical history (HPI): The principal complaint must be precisely documented in accordance with evaluation and management documentation criteria in order to prove medical necessity. According to regulations, only the doctor may record the HPI.
  • Noting the results that are positive: Whether a diagnosis is ruled in or out depends significantly on both positive and negative findings. Keep in mind the saying, “If it’s not in writing, it didn’t happen.”
  • Only providing a diagnosis list at each evaluation session: The evaluation is the part of the daily contact where the physician documents his or her perspective of the situation. Just mentioning the diagnosis for each visit may not be sufficient to prove medical necessity.

Processing delays are caused by incomplete medical records. A person in urgent need of care is not receiving care for an additional hour for every hour that documentation is delayed. Accurate documentation ensures that the patient receives proper care when they need it while lowering any risk exposure to patients and healthcare organizations. Good clinical records can be utilized to investigate any major incidents in the patient’s care as well as to audit the quality of the healthcare services provided. Utilizing medical transcription services is the most effective way to ensure the accuracy of medical documentation. Compared to using speech recognition software alone, these services reduce the number of errors and increase the accuracy of records.

Reach out to us today and discover how our friendly team of experts can assist you with top-notch transcription services.

Ask for our Free Trial

How do Medical Transcription Services help Therapists Maintain Good Clinical Documentation?

26-January-2023 MTS TEAM Medical Transcription

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, are required to document many types of notes from patient to patient and meet regulatory standards of practice and maintain appropriate, HIPAA compliant documentation. Outsourced medical transcription services can help therapists overcome the challenges of maintaining good clinical documentation.

Clinical Documentation in Behavioral Health

Therapy notes describe what occurred during a session, outline the general treatment plan, provide an idea about the patient’s mental health state, and document next course of action in the treatment. Discussed below are the different types of notes maintained by behavioral health providers:

  • Psychotherapy notes or process notes: Mental health professionals maintain psychotherapy notes or process notes to document the details of the conversation during a private individual, group, joint, or family counseling session. These notes cover observations, the patient’s demeanor, hypotheses about a diagnosis, thoughts and feelings about the session, and questions. Psychotherapy notes are kept separate from progress notes. These notes cannot be released without authorization and excluded from the provision that allows patients to see their health information.
  • Progress notes: These notes include assessment, diagnosis, and treatment interventions, referrals, preventive services, and coordination of care with other healthcare providers. Progress notes more formal than process notes and include elements such as diagnosis, prescriptions and type of therapy with session dates and stop times, and all other components necessary for billing and reimbursement purposes. Providers should also document any unusual challenges the patient faced during the therapeutic process and how they were addressed. Progress notes must be objective, concise, relevant and well-written.
  • SOAP Expanded as Subjective, Objective, Assessment and Plan, the SOAP format is a widely used format structure for progress notes. It allows healthcare professionals to capture and communicate patient information from a session in a clear, concise way. Writing proper SOAP notes can go a long way in improving the quality of care.
  • SOAIGP: This format is more detailed than SOAP. SOAIGP expands to Supplementary Database Information, Observations, Activities with and on behalf of the patient, Impressions and Assessment, Goals and Plans for next actions by the worker and client.
  • BIRP: BIRP – Behavior, Intervention, Response, and Plan – is another option to document a patient’s treatment and progress. It allows therapists to organize their notes into these specific sections and ensure that patients who see multiple providers to get continual care.
  • DAP: DAP stands for Data, Assessment and Plan. This is one of the latest ways to write a psychotherapy or progress note. DAP notes combine the subjective and objective sections in SOAP notes into one comprehensive section. DAP notes allow therapists to quickly document individual and group psychotherapy sessions.
  • Group notes: Well organized documents are necessary for family therapy and other types of group sessions. In addition to the group summary and synopsis, therapists must document identifying information and details for each participant – from mood and body language, participation, issues between group members, objectives and goals for each patient and how they can achieve them to interventions, client feedback, and plans for future sessions.

According to Catalysts Counseling, therapists can make the record keeping process easier by keeping the phrase “golden thread” in mind when documenting diagnosis, the progress note, and the treatment plan. These three elements should all link together when documenting patient interactions.

READ MORE: How To Write Good Mental Health Progress Notes

DAP vs SOAP Therapy Notes? What Are the Differences?

Role of Mental Health Transcription Services

As they focus on their patients, relying on a HIPAA-compliant mental health transcription service provider can help therapists maintain clear, confidential, well organized and timely clinical notes. The benefits of partnering with an experienced transcription company are:

  • HIPAA-compliant documentation: When it comes to mental health, the most important principles under HIPAA are with regards to privacy, security, and breach. Under the HIPAA Privacy Rule, the following information is subject to stringent privacy regulations (icanotes.com):
  • Any identifiable health information regarding the individual’s past, present or future physical or mental health
  • The type of health care provided to the patient and the reasons for the type of care
  • Information relating to the past, present or future payment for the care and treatment provided

All mental health documentation should remain completely confidential unless therapists are required to share it with other healthcare professionals or their patients. Partnering with a HIPAA-compliant medical transcription company can help therapists maintain good documentation. Reliable service providers have stringent regulations in place to protect the security, privacy, and confidentiality of the protected health information.

  • Documentation of large volumes of records in quick turnaround time: Experienced medical transcription companies can handle transcription tasks of any volume in quick turnaround time. Therapists capture information from a variety of sources: referrals, the patient interview, additional information received from other providers and family members. Details about the patient’s appearance, emotional expression, and affect, and their reactions or interaction with the therapist during the interview should also be noted. Capturing all of this information in individual and group sessions can be extremely challenging but crucial to provide targeted therapy. Outsourcing transcription to an expert is an ideal way to deal with this.
  • Accurate, detailed documentation: A thorough mental health assessment is necessary to collect all the details about a patient’s symptoms and complaints. This will enable proper diagnosis and appropriate treatment planning as well as help identify potential referral opportunities, so that the patients can benefit from the planned treatment. Qualified medical transcriptionists are familiar with the terminology, jargon and slang used in mental health services and can ensure accurate detailed documentation of mental health assessment for the medical record. This will provide the basis for the development of all other clinical documentation.

Therapy notes are at the core of the patient encounter and allow providers to track the patient’s progress till treatment goals are achieved. Medical transcription outsourcing to a HIPAA complaint company can help therapists maintain good clinical documentation that meets stringent confidentiality standards.

MOS Medical Transcription Services has extensive experience providing customized clinical documentation solutions for all medical specialties. We can handle projects of any size in quick turnaround time.

Best Practices for HIPAA Compliant Email Communication

23-January-2023 Julie Clements HIPAA Compliance

HIPAA Compliant

Today’s technologies have made physician-patient communication easier than ever before. Email communication is a reliable way for healthcare providers to connect with their patients, colleagues, and other offices. When using email to transmit protected health information (PHI), organizations need protect against breaches. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects patient rights and privacy. While physicians prefer use secure online file storage with strong encryption to exchange PHI with their medical transcription service organization, ensuring HIPAA compliance is essential when sending PHI via email.

HIPAA compliance refers to the regulations that healthcare organizations must have in place within their business in order to safeguard the privacy, security, and integrity of PHI. Covered entities (anyone providing treatment, payment, and operations in healthcare) and business associates (anyone who has access to patient information and provides support in treatment, payment, or operations) such as email service providers and medical transcription service companies must comply with Rules’ requirements to protect the privacy and security of health information.

Importance of HIPAA-compliant Email for Physicians

When it comes to email, security should be a top consideration since this form of electronic communication is especially vulnerable to cyber attacks. Physicians who use email communication to send PHI externally need to encrypt it to be HIPAA compliant. An unencrypted email can be intercepted in transit or while it is at rest and read. Not encrypting email that contains PHI puts both patients’ privacy and the organization at risk of HIPAA violations. According to Steve Alder editor-in-chief of HIPAA Journal, measures to eliminate these risks and ensure HIPAA compliant email include (but are not limited) to the following:

  • Encrypting email
  • Having a business associate agreement in place with the email service provider
  • Implementing access controls on email accounts
  • Setting up procedures for backing up, retaining, or archiving emails containing ePHI, staff training, and
  • Documenting patient consent

Let’s take a closer look at the best practices for email communication in healthcare.

Best Practices to Make Email HIPAA Compliant

The following measures can make your email HIPAA compliant and protect email phishing attacks:

  • End-to-end email encryption: In end-to-end email encryption, a set of keys is used to encrypt the email before it is sent and to decrypt the message when it is received and stored. So, the encrypted data can be read only by those with decryption keys – the intended recipient and the sender. This prevents unintended users from viewing or modifying data. AES 128, 192, or 256-bit encryption is the currently recommended standard for data security. Organizations should implement the safety measures best suited to their needs. Small medical practices that do not have in-house IT staff to implement HIPAA-compliant email can rely on a third-party HIPAA compliant email service provider.
  • Sign a business associate agreement with the email provider: Before using third-party service provider for end-to-end email encryption, physicians should have them sign a business associate agreement. The agreement should cover all the important points: how the company encrypts email, where the encryption keys are kept (onsite, offsite, or another server, etc) who has access to the encryption keys, how the company keeps the keys safe and handles physical security, and so on. In other words, the agreement should clearly define the email service provider’s responsibilities and the administrative, physical, and technical safeguards they will use to ensure the confidentiality, integrity and availability of electronic PHI. Don’t partner with a company that is not prepared to sign a business associate agreement.
  • Configure email correctly: Simply using an email service that is covered by a business associate agreement is not sufficient to make email HIPAA compliant. Email should be configured and set up correctly. Gmail helps users set up a HIPAA compliant email account using G Suite, provided the service is used alongside a business domain. Note that Google signs a business associate agreement only with paid users upon the request of a systems administrator. Subscribers must ensure that the service is configured to ensure end-to-end encryption.
  • Train staff on using email to exchange PHI: Practices should train staff on sending HIPAA compliant email and avoiding data breaches. They should strictly implement policies on email use to ensure that the right information is always sent to the right recipient using the necessary encryption methods. Every employee should be fully aware of their responsibilities and about avoiding errors such as sending PHI via unencrypted email or to individuals who are not authorized to view the information. Organizations should ensure that their email account has a strong password and two-way authentication to check unauthorized access.
  • Email retention: Retaining emails will allow providers to access and recover data in an emergency or during a compliance audit. While HIPAA rules don’t specifically mention email retention, they require covered entities to store documentation related to their compliance efforts for 6 years. Covered entities should maintain a backup email archive or ensure that emails are backed up and stored. Organizations should check if the laws of the state where they are located require emails to be stored for a fixed period of time.
  • Obtain patient consent: Organizations should obtain patient consent before they start using email to send PHI. Even if the email provider is HIPAA compliant, patients must be informed that there are risks to the confidentiality of information sent via their email service. Patients should also be told about the risks involved if they view email containing PHI on a public or unsecured network. Patient consent should be documented once they understand and accept the risks, and after this is done, healthcare providers can send emails containing PHI without violating HIPAA rules.

HIPAA compliant email communication is necessary when communicating externally beyond the organization’s firewall and may not be needed for emails sent internally. As HIPAA compliance and the approach to it is evolving, healthcare providers need to stay updated on the rules and regulations. They must prepare their workforce to identify threats and follow best practices to ensure HIPAA compliant email communication. When it comes to EHR documentation, choosing HIPAA compliant medical transcription services is essential to ensure the confidentiality of PHI.

MOS Medical Transcription Services (MTS) is a HIPAA compliant medical transcription service organization. We provide secure HIPAA-compliant solutions for healthcare organizations across the US and strictly follow all HIPAA guidelines and best practices.

How Automation can Support Small Medical Practices

19-January-2023 Rajeev Rajagopal Medical Transcription

Small Medical Practices

Automation 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 the development of voice recognition systems that instantly transform physician dictation into readable text. With speech recognition technology, the role of medical transcription services has morphed into editing machine-generated transcripts.

In healthcare, automation is helping to simplify core processes and improve the provision of care. Using advanced technologies and software can help small practices address many of their common challenges, such as rising administrative burden, decreased time with patients, increased regulatory requirements, and much more. Using the right technologies can help small practices simplify processes, better handle these challenges and save time and money.

Processes That Small Medical Practices are Automating

There are many types of software that can make a difference in the way small medical practices operate. Success depends on choosing the options that can enhance operational efficiency, increase return on investment, and save time. Here are the areas that small practices can automate:

  • Appointment scheduling: The front desk is a great place to start automation. Scheduling appointments and sending appointment reminders is a time-consuming and tedious task for front desk staff. When done manually, these tasks can involve spending hours calling up patients to arrange or rearrange time slots, even as patients are waiting in line at the practice. Leveraging automation for managing appointments can make a big difference to both patients and providers:
     

    • correctly schedules/reschedules/cancellation of appointments without long wait times or confusion about dates
    • allows patients to schedule at a convenient time, day or night, with no busy signals or wait on hold
    • patient can make real-time updates to their appointment
    • providers can set up auto-confirmations and appointment reminders
    • enables high volume scheduling with consistent efficiency
    • provides data in digital format

Automated appointment scheduling frees up valuable staff time, enhances practice efficiency and improves patient satisfaction.

  • Data retrieval and sharing: Over the last decade, medical practices of all sizes have implemented electronic health records (EHRs) to provide care and obtain and share valuable data on patients. Today, EHRs are being integrated with advanced capabilities to generate data real-time, allowing providers to get the current, complete and accurate information they need instantly. Automation has improved EHR data retrieval and patient care.
  • Ordering and billing: Automation can be used to support key processes like ordering and billing. Predictive AI technologies can ensure that orders are completed with greater efficiency and speed. E-prescribing has become standard practice for many medical specialties. Prescriptions are sent to the pharmacy electronically from the point of care. E-prescribing can reduce the abuse and addiction rates of opioids and other controlled substances. Also, with electronic prescriptions, the EHR can automatically check for any potential drug reactions or allergies that could occur based on a patient’s current medication and diagnosis.

Medical billing is becoming more and more challenging by the day due to increased patient financial responsibility, complex payer contracts, and the change to value-based payments. Artificial intelligence (AI) is proving a game changer in revenue cycle management, making bill generation easier, faster, and error-free.

  • Practice management: Automating practice management with practice management software combines many functions and offers many advantages: streamlined processes and improved workflow across the entire practice, boost efficiency, and improved patient engagement and care. A well-implement, efficient system can grow your practice’s bottom line. As costly, incongruous systems can clutter operations and unnecessarily increase spending, a Medical Economics article recommends that practices should evaluate the software their practice uses and ensure it is working efficiently. If not, they should replace it with a cohesive, all-in-one solution.
  • Documentation tasks: Voice recognition technology is widely used to automate provider dictation and capture clinical information fast in real time. Best practice is for clinicians to document the patient consultation as close to the end of the appointment as possible. Even if they take brief notes, clinicians need to accurately describe the encounter. The main advantage of voice recognition is that it can be easily accessed from anywhere, anytime. However, as machine-generated documentation has possibility for errors, providers should ensure that it is vetted by a reliable medical transcription service provider.
  • Tracking patient health: Smartwatches, wearable medical devices, and smart thermometers collect data on pulse and blood pressure, heart activity, and temperature to identify illness and disease clusters. IoT (internet of things) enabled devices allow physicians to track patient health remotely and help them deliver care to keep patients safe and healthy. As with EHRs, healthcare providers should be aware about the data security concerns surrounding IoT.
  • Patient communications: Using chatbots is an effective way to answer common patient questions and to schedule appointments. Chatbots use machine learning and AI to simulate human communication, either through voice or text communication. During the coronavirus pandemic, chatbots were widely used in mental health care. Mental healthcare bots use cognitive behavioral therapy and apply techniques to help clients improve their mental health

Automation redefines healthcare by improving diagnosis, clinical decisions, and care and treatment outcomes. Technology reduces costs for patients, streamlines processes and workflows, and enhances both the provider and patient experience. Medical transcription outsourcing can help providers ensure accuracy in documentation created using voice recognition technology. With the many challenges that they faced over the past two years, healthcare practices need to ensure that they are using the right tools and strategies to deliver better care, improve patient satisfaction, and boost their bottom line.

Major Clinical Components of Dental Records

12-January-2023 Julie Clements Infographics

Medical records are essential documents that provide details about the patient’s history, clinical findings, results of laboratory tests, pre- and postoperative care and more. Like any other specialty, dental practices should also maintain accurate patient records that reflect the quality of service provided and how the treatment plan is progressing. Professional medical transcription services can help practices maintain reliable patient records.

Dental records include all details such as – medical history, diagnostic information, clinical notes, treatment plan, and patient-related communications that occur in the dentist’s office, including instructions for home care, consent to treatment, and financial information. All this information may be used to analyze the quality of care received and to effectively plan therapy in the future. Well-managed records serve as a channel for communication between the treating practitioner and other oral health care experts or clinicians who may be assigned to that patient. Dental records should include enough information for another practitioner to comprehend the patient’s visit to the practice.

Dental Records

Different Components of Dental Records

The data in the patient chart should be clinical, encompassing all essential patient information, medical history, and encounters with your office and other oral health care experts. The following are key components of dental records:

  • Registration form: The registration form asks for specific information such as the patient’s name, address, work, and mailing address, among other things. Due to privacy concerns, a patient’s social security number will not be sought unless the office can demonstrate that it is required to utilize this number rather than an alternative specific identifier issued by the practice. If the office demonstrates a necessity, the practice must be able to protect sensitive information from intruders or computer hackers by blocking or encrypting it. The office will frequently need a Signature on File form if the patient is covered by insurance. When the patient or parent/guardian signs this, it allows billing to insurance without the patient needing to sign each time. This signature can be attached if it is gathered electronically.
  • Medical and dental history: Dental professionals must gather all essential and relevant medical information prior to beginning treatment in order to provide safe dental care. Medical and dental histories should be taken in a methodical manner, noting the patient’s current state of health as well as any major illnesses, ailments, or previous adverse reactions that could affect clinical therapy. Any significant dental history, such as an assessment of caries risk and periodontal health, must also be recorded in the patient’s report. Every patient is different, and while planning and sequencing dental care, the dental history should be taken into account alongside the clinical evaluation.

Vital signs can be taken and added to the history once the patient is seated for treatment. When using an automatic machine to take the patient’s blood pressure and pulse rate, as well as their temperature, these can be added to the document. This gives you a chance to talk about the patient’s health in a more private setting.

The dentist is ultimately responsible for keeping the patient history up to date. The patient fills out the medical history form. If the patient is a minor, the parent or legal guardian should fill out the form. The form can be filled on paper or in an electronic format in either scenario and mailed ahead of time if they are on paper.

  • Progress report: Progress notes are an important part of the patient’s file. Progress notes should be completed at or immediately after each appointment to ensure treatment continuity, and they must be reviewed and approved by the treating doctor. The level of information necessary varies by patient and treatment, but all progress reports should include the following:
    • The treatment date
    • A brief yet comprehensive explanation of all services offered
    • The identity of the treating physician
    • The type, amount, and outcome of any anesthetics utilized, as well as the materials and methods used
    • The results of the radiographs
    • All suggestions, counsel, and talks about potential consequences or results

Also read: 4 Best Practices to Maximize Efficiency in Dentistry Transcription

Ensuring Dental Record Accuracy

Errors or incorrect information should never be erased or removed from the chart to avoid accusations of tampering. Instead, they should be struck out in a way that preserves the readability of the original notation. Electronic records must be accompanied by an audit trail that achieves the same goal. Entries that are late should be clearly labelled as such. After receiving a claim for compensation or notice of legal proceedings, a clinician should never add to or amend a patient’s chart. Any alterations made in this context would be seen as self-serving, if not outright fraudulent.

Clinical and financial data, as well as radiographs, consultation reports, and medicine and lab orders, must all be kept for a minimum of ten years from the final entry in the patient’s record. These records must be retained for at least ten years after the patient reaches the age of eighteen years in the case of a minor.

The dentist must keep a patient record for all patients who come to the office. He/she should know the medical history of each patient and the condition of their teeth. This will help make the right diagnosis. In addition to this, the dentist must also keep a record of any treatment given to the patient. This will help in fixing the problems that may arise during future appointments.

A reliable provider of dentistry medical transcription services can assist dentists in maintaining an accurate patient record. All dental records can be stored online and accessed whenever required. In addition, it also helps maintain patient privacy as all the data is stored on secure servers with advanced encryption techniques.

Ensure accurate, compliant, and secure patient records with professional medical transcription services.

Contact us today!

How to Prepare Different Types of Medical Transcription Reports

09-January-2023 Rajeev Rajagopal Medical Transcription

Medical Transcription Reports

A 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 help them track the patient’s progress, make informed decisions about treatment, and communicate with each other Medical transcription services ensure that this information is recorded and transcribed accurately and is easily accessible to all healthcare professionals involved in the patient’s care.

Accurate medical records are essential for providing high-quality patient care as they contain important information about a patient’s medical history, diagnoses, treatments, and progress. Medical transcription reports come in various types, each serving a specific purpose. These reports serve as a crucial part of the patient’s medical record. They ensure that accurate and complete medical records are maintained, facilitate communication between healthcare professionals, reduce errors, and improve the overall efficiency of the healthcare system.

Experience the power of accurate and comprehensive medical transcription reports, tailored to your specific needs.

Contact us today to learn more

Medical Transcription Reports

Different Types of Medical Transcription Reports

Medical transcription reports provide a comprehensive record of a patient’s care. They are used to track a patient’s progress, identify any issues or concerns, and ensure that the patient receives the best possible care. These reports may be used to support claims or to defend against medical malpractice lawsuits. Here are the different types of medical transcription reports:

  • Physical and History Report: When a patient is admitted to the hospital, the admitting doctor or a resident typically orders this report. Usually, the main complaint comes first. The term “history” refers to the past medical history, social history, family medical history, and history of the current sickness. System reviews and a thorough physical examination from head to toe are typical. The report typically concludes with the patient’s treatment plan and the admission diagnosis.
  • Consultation Report: Usually, a doctor who was referred to by the admitting doctor to treat the patient will write this report. As a result, the consulting physician typically has a different area of expertise than the admitting physician. For a second opinion, consultations are occasionally requested. Depending on the exact kind of consultation required, consultation reports typically include a succinct description of the patient’s disease and a specific physical examination. Also, the report might contain laboratory or x-ray results. The report often concludes with the consulting doctor’s assessment and treatment recommendations, and occasionally with a statement in which the consulting doctor expresses gratitude to the admitting doctor for the referral.
    For information on transcription of consultation reports, read our blog post: Consultation Reports in Medical Transcription
  • Operative Report: This report, which is being dictated by the operating physician, contains specific details about an operation and its procedure. Preoperative and postoperative diagnoses, the kind of surgery (or surgeries) that were performed, the names of the surgeon and the attending nursing staff, the kind of anesthesia and the name of the anesthesiologist, and a thorough description of the surgical procedure itself are all included in this report. Information on instrument counts, sponge counts, and blood loss are also determined by the surgical procedure. The report will frequently conclude with a disposition, the location to which the patient was taken after he left the operating room (typically the recovery room), and the patient’s state at that time.
  • Radiology Report: Following a diagnostic procedure, the radiologist writes a report that incorporates his or her observations and impressions. X-rays, CT scans, MRI scans, nuclear medicine treatments, and fluoroscopic examinations are some examples of radiology reports.
    Learn more: Need to Improve Radiology Reports – Outsourcing Medical Transcription can Help
  • Pathology Report: This pathologist-written report summarizes the results of a tissue sample. The report’s main emphasis is on the sample’s microscopic findings and pathological diagnosis.
  • Laboratory Report: This report details the results of tests done on biological fluids like blood and urine. Rarely are laboratory reports dictated separately; instead, they are frequently part of the H&P, consultation, or discharge summary.
  • Miscellaneous Report: It includes reports from various hospital procedures like autopsies, electrophysiological tests, phacoemulsification, cardiac catheterizations, and psychiatric evaluations.

Revolutionize your documentation process with precise, reliable, and efficient medical transcription services.

Call us at (800) 670 2809

Healthcare providers are better equipped to provide comprehensive care when they have access to complete and accurate medical transcription reports. Choosing reliable medical transcription services can ensure that every single piece of information is documented accurately and in fast turnaround time.

  • KEY FEATURES

    • 3 Levels of Quality Assurance
    • Accuracy Level of 99%
    • All Specialties Covered
    • Competitive Pricing
    • Digital Recorder Dictation
    • Electronic Signatures
    • Feeds for EHR or EPM
    • HIPAA Compliant Service
    • Quick Turnaround Time
    • Toll Free Phone Dictation
    • Transcription Management Software
    • Volume Rates Available

  • RECENT BLOGS

  • Categories

  • Quick Contact








      • Infographics