Avoid Misinterpretations of Abbreviations in Medical Record Documentation

05-January-2023 MTS TEAM Medical Transcription

Medical Record Documentation

Medical abbreviations and acronyms or “acceptable” terms that physicians and other healthcare professionals generally use in patients’ medical records. Medical transcription service providers make sure that their staff is well-trained in documenting abbreviations, including converting them to their acceptable form when dictated. The benefits of using medical abbreviation while writing notes and drug orders are:

Convenient
Saves time
Allows fitting a word or phrase into a restricted space
Reduces risk of misspelling words
Eases communication among physicians and staff
Improves efficiency

Healthcare staff who read and process the physician’s orders should be familiar with these acronyms and terminologies. Using inappropriate abbreviations and not interpreting them correctly can result in patient harm. Let’s take a look at expert recommendations on how to avoid misinterpretations of abbreviations in medical record documentation.

Problems Associated with the Use of Medical Abbreviations

Medical abbreviations are used in all medical and surgical departments, during surgery, the emergency room, and at discharge. However, while using medical abbreviations is widely accepted, rampant use and inappropriate abbreviations can result in miscommunication. This will lead to errors in the medical record, especially medication errors, and pose a threat to patient safety. National Medication Error Reporting program run by the US pharmacopeia MedMarx reported that 643,151 medication errors were found by 682 subscribing facilities of which 4.7% (29,974) were attributed to use of medical abbreviations (cited from an article published by StatPearls Publishing LLC, August 2022).

Careless use of medical abbreviations and acronyms in the medical record

Communication problems: The failure to communicate properly is one of the major reasons for medical errors. Healthcare providers use serious medication abbreviations when writing drug orders. Junior staff are responsible for understanding the abbreviation. However, medical abbreviations can have multiple meanings or contradictory or ambiguous meanings. If junior staff cannot decipher or interpret the abbreviation in the medical chart or a drug prescription, they will be unable to carry out the order (if they cannot clarify it with the physician).
Can put patient safety at risk: Use of medical abbreviations that can have multiple meanings can lead to further communication lapses and put patient safety at risk. If junior staff misunderstands, misreads, or incorrectly interprets the abbreviation, it can cause serious errors in dispensing or administration of a medication or a test. These issues can delay care and even jeopardize the patient’s safety.
Specialty-specific concerns: Each medical specialty has its own acceptable terminologies. For instance, a transcription company providing orthopedics transcription services would need to be well-versed in abbreviations used in orthopedic progress/consult notes. However, these speciality specific abbreviations used within a practice may not be recognizable to those not working within the same field.
Errors in the medical chart: With the widespread adoption of electronic health records (EHR), medical abbreviations are often repeated in the medical chart and will continue to pose risks to patient safety. Moreover, the EHR autocorrect tool which can speed up medical transcription can easily cause errors. Injury attorneys Lowenthal & Abrams cite the example of a patient whose chart said she had presented with “morphine sulfate”, which is a drug, not a symptom. The mistake was found when the attending nurse cross-checked the patient’s outside chart against her medical history – the notation of “MS” which was meant to indicate Multiple Sclerosis was mistaken as morphine sulphate (lowenthalabrams.com).

Common Medical Abbreviation Errors

Every medical chart or a drug prescription in any healthcare institution will have at least one abbreviation per page in the patient’s medical chart, note the authors of the article published by StatPearls Publishing LLC. According to data from National Medication Error Reporting program:

The three most common types of errors due to the use of medical abbreviations were errors in prescribing, improper dose/quantity and incorrect preparation of the medication.
The most common medical abbreviation error was the use of QD (once daily), which accounted for 43.1% of all errors. The next was the use of U for units, cc for ml and other decimal errors.
Use of MS or MS04 for morphine sulfate (mistaken as magnesium sulphate) was the most common drug abbreviation name that led to an error.
Up to 81% of the errors were found to occur at the time of ordering the medication
The administration, procurement, and monitoring process was associated with less than 2% of the total errors.

The program also found that errors in medical transcription and in the dispensing area occurred were less frequent.

Here’s a list of common error-prone medical abbreviations, symbols, and dose designations and best practices (www.ismp.org):

l – Liter: Lowercase letter l mistaken as the number 1 – Use L (UPPERCASE) for liter

Ng or ng – Nanogram: Mistaken as mg or as nasogastric – Use nanogram or nanog

IN – intranasal: Mistaken as IM or IV – Use NAS (all UPPERCASE letters) or intranasal

HS – Half Strength: Mistaken as bed-time (hs) – Use half-strength

BIW or biw – 2 times a week: Mistaken as 2 times a day – Use 2 times weekly

IJ – Injection: Mistaken as IV or intrajugular – Use Injection

APAP – acetaminophen: Not recognized as acetaminophen – Use acetaminophen

MgSO4 – magnesium sulphate: Mistaken as morphine sulphate – Use complete drug name

Lack of a leading zero before a decimal point (such as .5 mg) 0.5 mg: Mistaken as 5 mg if the decimal point is not seen – Use a leading zero before a decimal point when the dose is less than one measurement unit

# – Pounds: Mistaken as a number sign – Use lb if referring to pounds

How to Avoid Misinterpretations of Abbreviations in Medical Record Documentation

Though using abbreviations can save time, incorrect interpretation of these abbreviations is unacceptable. Best practices to avoid errors associated with medical abbreviation use:

Adhere to the standard for the appropriate use of abbreviations and minimum list of dangerous abbreviations, acronyms, and symbols published by the Joint Commission (JC).
Follow recommendations from the Institute for Safe Medication Practices, which includes:
- Avoiding abbreviating drug names entirely
- Being extra careful when abbreviating health syndromes, diseases, and conditions
- Being alert to problems caused by certain abbreviations, for e.g., B for breast, brain, or bladder.
- The person who uses an abbreviation must take responsibility for making sure that it is properly interpreted
Develop a list of approved and not approved medical abbreviations.
Educate all staff on the dangers of using abbreviations

Encourage junior staff to communicate with senior staff who write the abbreviations before carrying out the order
Conduct regular audits to check for compliance
Disallow use of medical abbreviations on all patient charts, discharge forms, consent forms and prescriptions

Outsourcing medical transcription to an expert can help avoid misinterpretations of abbreviations in medical record documentation. Physicians should choose a company that has trained and experienced medical transcriptionists. These professionals receive special training on abbreviations and acronyms in the medical record, which includes converting error-prone abbreviations to their acceptable form when dictated.

MOS Medical Transcription Service has years of experience in multi-specialty transcription. We are 100% HIPAA-compliant and can provide customized transcription solutions in quick turnaround time.

How Medical Transcription Solutions can Optimize Physician Satisfaction

02-January-2023 Julie Clements Medical Transcription

Medical Transcription Solutions

The role and responsibilities of physicians have expanded considerably over the last two decades. From the dynamics of the healthcare system, rapid advances in technologies, and changing industry regulations to the growing population of older adults and rising incidence of chronic diseases, many factors have increased the responsibilities of today’s physician. While their specialties might differ, physicians work to diagnose and treat injuries and illnesses and medical transcription outsourcing helps them to document medical histories, diagnostic tests, treatment plans and much more. Comprehensive medical transcription solutions ease the medical documentation task and go a long way to optimize physician satisfaction.

Impact of Physician EHR Data Entry

Several studies have reported that the time physicians spend on EHR documentation is one of the major reasons for physician burnout. According to a study by the University of Wisconsin and the American Medical Association, 5.9 of the 11.4 hours that physicians work per day are spent directly engaged with their electronic health record. A study published by JAMA Internal Medicine based on the 2019 National Electronic Health Records survey found that physicians spend an average of 1.84 hours a day completing documentation outside work hours. Here are the other findings of the JAMA study as summarized by Becker’s Hospital Review:

Nearly 33% of physicians spend two hours or more completing documentation outside work hours daily.
41% of physicians agreed the time they spend completing documentation is appropriate.
57% of physicians said time spent documenting reduces the time they can spend with their patients.
85% of physicians agreed that documentation done solely for billing increases their total documentation time.

The researchers estimated that physicians spent a total of 125 million hours completing documentation outside work hours in 2019.

When physicians spend too much time on data entry at the encounter, it reduces face-to-face time with the patient. They cannot give patients the attention they deserve when they are looking at the computer screen. This can affect quality of care and reduce patient satisfaction.

Experts strongly recommend scribe support as a practical option for physicians to manage the tedious and time-consuming EHR documentation task. Outsourced medical transcription services are available for healthcare entities of all sizes. An expert can ensure accurate and timely documentation for all medical specialties.

Top Benefits of Medical Transcription Services

While technology-based strategies such as speech recognition can help physicians complete EHR documentation quickly, having the files checked by a human transcriptionist is crucial to ensure accuracy. Medical transcription solutions can improve physician satisfaction in many ways:

Reduces physician burnout: By handling EHR data entry, medical transcriptionists improve the physician experience and reduces the strain caused spending too much time on documentation when seeing patients. This improves the physician’s quality of life by giving them more time for patient care as well as for extra-curricular activities.
Eliminates EHR-related distractions: With support for EHR data entry tasks, physicians can better focus on and interact with the patient at the visit, which will improve patient satisfaction scores.
Makes time to see more patients: By eliminating EHR data entry work and saving time, medical transcription support can help physicians see more patients. Practices can increase daily visits per provider with the right support.
Improves report quality: EHR shortcuts were designed to improve physician efficiency, but can have the opposite effect. In fact, EHR shortcuts like copy-and-paste and the capability to insert blocks of text automatically can lead to note bloat and reduce the value of the documentation by ignoring encounter specific conditions. These functions, if not properly utilized, can lead to errors, make documentation difficult to comprehend and affect patient care as well financial outcomes. Proofreading of machine-generated transcripts and addressing errors that could be caused by use of other time-saving EHR shortcuts by medical transcriptionists improves report quality.
Reduces risks to patients that can occur due documentation errors: Documentation errors can occur due to not correctly reporting a patient’s condition, medications administered, or anything else related to patient Transcription services can reduce the risk of such errors that can result in poor care outcomes.
Improves care and medication adherence for chronic conditions: A study published in The Journal of the American Geriatrics Society found that patients over age 65 with multiple chronic conditions who had access to EHR clinical notes were more likely to report greater medication adherence than other patients. Patients with more than two chronic conditions were more likely than those with fewer or no chronic illness to report that reading their notes helped them stay engaged in their care, said the researchers. Health systems should strive to ensure that all older patients have access to appropriate information in a format that is most usable and useful for them (ehrintelligence.com). Geriatricians can ensure quality medical reports with support from a reliable geriatrics transcription service
Increased revenue: An article in For the Record references a discussion in which physicians said they suffered a personal annual income loss of $80,000 to $100,000 as they were forced to see less patients due to increased documentation time. Scribe support to ensure complete, accurate and richer documentation allows for better reporting of hierarchical condition category (HCC) codes and other claim-influencing data, and promotes opportunities for improved revenue, notes the report.

By ensuring end-to-end support for clinical documentation, medical transcription solutions can optimize physician satisfaction and efficiency, and free up their time not only for patient care but also personal pursuits. By ensuring quality documentation, medical transcription support can also drive better financial outcomes. Choosing an expert is crucial to get the right support and significant cost savings.

MOS Medical Transcription Services ensure HIPAA-compliant compliant documentation solutions for all specialties. This US-based company has a team of experienced medical transcription specialists and quality control experts who can provide real-time, EHR-integrated medical transcription.

Transcribing Medication Orders

Physicians prescribe medications based on the diagnosis. Licensed practical nurses or registered nurses are authorized to transcribe medication orders. When the transcripts reach the pharmacy, pharmacists dispense the prescribed medication volumes and doses. The medications are then administered to the patient.

It is critical to ensure accurate and timely transcription of the medication in the medication administration record. Following these basic guidelines when transcribing medication orders can prevent errors and ensure patient safety in medication administration:

Writing legibly or typing correctly so that all concerned persons can read it.
Transcribing exactly as the order is written by the practitioner and current prescription label on the medication container.
Ensuring that medication orders are transcribed in the medication record at the time medication is ordered.
Using only facility-approved abbreviations.
Check the prescription order to ensure accuracy in the following details: patient name, date, medication, dose, route, time, documentation, reason, and response.
Any doubts in the written or dictated prescriptions must be clarified with the physician who made the order.

However, in facilities where large volumes of medications are prescribed, even licensed nurses can make mistakes in transcribing medications.

Medication Transcription Errors

A 2019 study published in BMC Health Serv Res. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6729077/) focused on medication errors occurring at the medication transcription stage. The researchers listed the various interpretations of medication order transcription errors described by previous studies, which are as follows:

Inconsistency between the physician medication order and the medication order transcribed
Mistakes while transcribing medication orders from the previous prescribing step
Incomplete and/or wrong transcription of a medication order
Mismatch between the medication prescription and what was transcribed on the nurse’s administration form
Discrepancies in the names of the drugs, their formulations, routes of administration, doses, dosing regimens, omission of drugs, or addition of drugs which were not ordered or prescribed

The researchers cited previous studies that reviewed errors that occurred at the medication transcription phase:

One study found that nurses transcribed chemotherapy and non-chemotherapy related prescribed medications onto different sheets twice. In the first transcription stage, there were inaccuracies in 11.8% and 20.7% of the transcribed chemotherapy and non-chemotherapy medications, respectively.
Another study found medication transcription errors in 16.9% and 13.8% of the 6583 and 5329 medications transcribed onto inpatient profiles and discharge charts, respectively.
A teaching hospital based study found medication transcription mistakes in about 30% of the 558 opportunities for errors.

The BMC study researchers emphasized that medication transcription errors are particularly a matter of concern because “the different phases of prescription, transcription, dispensing, and administration occur in chain and, therefore, it is highly likely that if a medication was transcribed incorrectly, this error would go without interception and would most probably reach the patient and cause harm”.

In large hospitals, where larger volumes of medications are prescribed, there is an increased chance for errors and potential harms to the patients.

Prevent Medication Documentation Errors with Outsourced Medical Transcription Services

Today, medical practices and hospitals with high-volume transcription requirements outsource the task to ensure accurate and timely medical record documentation. Medical transcriptionists are trained and certified to transcribe medication orders and many other types of reports that physicians dictate. Reliable US based medical transcription companies put all transcripts through a stringent quality assurance process, and can provide error-free, HIPAA-compliant documentation at cost-effective rates.

MTS Transcription Services (MTS) provides real-time medical transcription services for hospitals, clinics, and individual physicians throughout the United States. The company has a team of skilled and experienced medical transcriptionists, editors and proofreaders that can meet the medical transcription needs of hospitals, physician practices, medical centers, and more.

Trust MOS for reliable, secure, and confidential medical transcription services.

Click here to learn more about our nursing transcription services.

Tips to Document Clinical Notes On Time [INFOGRAPHIC]

22-December-2022 Julie Clements Infographics

Accurate documentation of clinical notes is crucial for any healthcare facility’s successful running. Providers can consider relying on professional medical transcription services to create consistent and accurate documentation of recorded material. The Journal of AHIMA has stated that the main goal of documentation in healthcare facilities is to guarantee that patients receive the treatment they require by providing medical professionals the data they need to make informed decisions. Medical records that are clear and precise guarantee that the patient will receive proper care from any doctor or nurse who is starting their shift.

Not only the treatments provided, the patient’s file should also include a diagnosis and treatment strategy. It is also important for providers to know the requirements for E/M documentation. They can save time by following the rules and simply documenting what is required for the present day’s visit in terms of medicine.

Error-free documentation ensures that services and treatments can be paid correctly to the patient or insurance provider. Maintaining accurate medical records also reduces the risk of malpractice and ensures that the hospital can bill claims effectively. Medical dictation transcriptions must be accurate in order to guarantee proper patient care. Medical transcription outsourcing services that include individualized medical transcribing solutions are critical for medical practitioners to maintain quality data.

Check out the infographic below

Clinical Notes

What are the Documentation Requirements for the Anesthesia Record?

19-December-2022 Rajeev Rajagopal Anesthesiology Transcription

Anesthesia Record

Documenting anesthesia care in the patient’s medical record accurately and thoroughly is essential to communicate the patient’s anesthetic experience. The anesthesia record should document relevant anesthesia-related information in an accurate, complete, and legible manner. Anesthesia care comprises three phases: preanesthesia, intraoperative/intraprocedural anesthesia and postanesthesia care. Anesthesiology transcription services play a key role in helping providers capture a detailed account of the three phases of anesthesia related care.

Importance of the Anesthesia Record

The anesthesia record provides information about detailed perioperative care, which includes preoperative assessment, anesthesia management, vital parameters, and intraoperative events. Accurate and complete anesthesia documentation is a must for the following reasons:

to enable preanesthetic planning
to provide pertinent information to other healthcare providers who will be involved in patient care
to support quality care and management of critical events
to serve as protection in a potential medical malpractice claim
to meet all applicable regulatory, legal and billing compliance requirements
to facilitate any future necessary chart review
to drive quality improvement activities
for future research

The transition from paper records to electronic medical records (EMRs) enables anesthesiologists to ensure a legible record with standardized documentation, and facilitate greater access to information to optimize patient outcomes and meet other goals.

Anesthesia Record Documentation Essentials

The requirements for the anesthesia record will differ based on the specific requirements for an anesthetizing area or facility. These areas include the operating room, labor and delivery, remote locations, pain management, clinical services (e.g., resuscitation, intubation, IV insertion), and clinic or office settings. Also, the requirements for documentation will tend to change over time based on practice improvement goals, reimbursement and other requirements.

The American Society of Anesthesiologists (ASA) lists the documentation requirements for preanesthesia, intraoperative/intraprocedural anesthesia and postanesthesia care as follows:

1. Preanesthesia Evaluation

A. Patient assessment data: Patient and procedure identification; Anticipated disposition; Medical history – includes patient’s ability to give informed consent; Surgical and Anesthetic history; Current Medication List (pre- and post-admission); Allergies/Adverse Drug Reaction (including reaction type); NPO status; presence of and the perioperative plan for existing advance directives.
B. Physical examination, including vital signs, height and weight and documentation of airway assessment and cardiopulmonary exam.
C. Evaluation of objective diagnostic data (e.g., laboratory, ECG, X-ray) and medical records.
D. Medical consultations (as applicable).
E. Assignment of ASA physical status, including emergent status when applicable.
F. The anesthetic plan – including plans for post-anesthesia care and pain management.
G. Documentation of informed consent (risks, benefits and alternatives) of the anesthetic plan and postoperative pain management plan.
H. Appropriate premedication and prophylactic antibiotic administrations (if indicated).

II. Intraoperative/procedural anesthesia (time-based record of events)

A. The following information should be documented immediately before the start of anesthesia care and anesthesia procedures:

Patient re-evaluation
Confirmation of availability of and appropriate function of all necessary equipment, medications and staff.

B. Physiologic monitoring data, such as recording of results from routine and nonroutine monitoring devices.
C. Medications administered: dose, time, route, response (where appropriate).
D. Intravenous fluids: type, volume and time.
E. Technique(s) used.
F. Patient positioning and actions to reduce risk of adverse patient effects/complications related to positioning.
G. Additional procedures performed such as vessel location, catheter type/size, specific insertion technique, actions to reduce the chance of related complications, stabilization technique and dressing.
H. Unusual events during surgery and anesthesia care.
I. Patient status at transfer of care to staff in a Postanesthesia Care Unit (PACU) or an area which provides equivalent postanesthesia care such as the ICU.

III. Postanesthesia

A. A time-based record of events that reflects the patient status on admission and discharge from the Postanesthesia Care Unit (PACU), as determined by preset discharge protocols or admission to the intensive care unit.
B. If the PACU is circumvented, criteria demonstrating that patient status at transfer of care are appropriate.
C. Significant or unexpected post-procedural events/complications.
D. Postanesthesia evaluation documenting physiologic condition and presence/absence of anesthesia related complications or complaints.

The ASA states that it is not the responsibility of the anesthesiologist to document the patient’s condition throughout the PACU stay or when leaving the PACU.

The ASA also provides the specific guidance for documentation in emergency situations: “In specific circumstances (e.g. emergencies, rapidly developing critical events, time sensitive sequential clinical care activities) an anesthesiologist or anesthesia care team member may be in conflict between a primary obligation to ensure patient safety and best clinical care, and contemporaneous medical record documentation. In these circumstances, attention to clinical care requirements remains the primary obligation. Medical record documentation should be provided as soon as appropriate in view of competing, primary clinical care requirements”.

Consequences of Missing/Wrong Information in Anesthesia Record

The anesthetic record is a permanent record of the events of perianesthetic care, which enables essential preanesthetic planning. However, a report in www.anesthesiallc.com notes that anesthesia documentation has been found to contain incorrect entries, missing data, incomplete descriptions and conflicting information. Common anesthesia record documentation errors, according to reports, include:

Documenting the surgical procedures section of a patient’s anesthesia record before the surgery is completed
Lack of clarity in the documentation stating the primary purpose of postoperative pain management
Incomplete/missing information regarding vital signs, details regarding adverse events, data for quality reporting and CMS documentation requirements.

Documentation errors can not only impact patient safety but also cause issues with billing. Hospitals and practices should that ensure documentation is done by the right provider at the appropriate time. Today, most providers are outsourcing their medical record documentation tasks to avoid errors. Medical transcription outsourcing companies that specialize in anesthesia transcription can ensure accurate and thorough documentation for all three phases of anesthesia related care. This will ensure proper and well-organized anesthesia administration to support patient care, reimbursement, quality improvement, and chart review by external organizations. By ensuring complete documentation, medical transcription outsourcing will also allow anesthesia providers to spend more time focusing on patient safety and quality. The documentation can be reviewed and analyzed, which may provide valuable insights into how to improve anesthesia delivery and the overall surgical care experience.

MOS Medical Transcription Services provides medical transcription solutions for all specialties. Our medical transcription company is focused on delivering accurate EHR-integrated transcription services in quick turnaround time.

How Can Physicians Find More Time To Provide Quality Care?

15-December-2022 MTS TEAM Medical Transcription

Quality Care

Getting important work done in a day is every professional’s dream. For physicians, efficient time management can ensure more time to provide quality care. When faced with a rising influx of patients with chronic conditions, flu, and other infectious diseases, making time to provide the personal attention and care patients deserve can be a challenge. According to research from The PwC Health Research Institute, patients expect the same facilities and customer service from their physician as they would from a bank, hotel or airline! Proper time management is essential to provide patients that kind of service and personalized attention. While medical transcription outsourcing is an effective way option to cut down time spent on EHR documentation, there are many other strategies physicians can use to find more time to provide quality care, and also maintain work-life balance.

Need for Effective Time Management

With the emphasis on value and efficiency in health care delivery, the time that physicians spend on patient care is an important resource. However, the increasing amount of time physicians spent on documenting care and performance metrics and meeting practice administrative requirements take away time spent with patients. Medical Economics reported on a new study which found that primary care providers (PCPs) require an average of 26.7 hours to effectively carry out administrative tasks and provide care to their patients on a given day. Out of that non-clinical time, physicians need to spend over three hours a day on documentation and inbox management alone, according to the research published in The Journal of General Internal Medicine.

Strategies for Physicians to Save Time for Patient Care

There are only 24 hours in a day. Effective time management is essential for physicians to find more time to provide quality care. Here is a list of strategies that can help physicians find more time for patients:

Delegate tasks to a virtual assistant: Hiring a virtual assistant can help physicians free up more time for patients. Every day tasks that a virtual assistant can help with include: managing calls, patient appointment scheduling and cancellation, securing and organizing medical records, email management, verifying patient eligibility, handling patient payment inquiries, and managing administrative tasks such as bookkeeping. A virtual assistant can be hired part-time, to meet project needs, or full time. With the right virtual office support, physicians can improve front desk efficiency and ensure that patients get the attention they deserve.
Minimize distractions and reclaim time: Physicians should limit activities that can affect productivity and time with patients. According to a 2021 Cureus study that looked into physician usage of social media platforms, 26.6% of the 158 participants spent less than an hour on social media, 31% spent one to 2 hours, 28.5% spent 2 to 3 hours, and 13.9% reported spending more than 4 hours during the day. Using social media professionally may be necessary, but casual scrolling on social media for hours can be a major time-waster for physicians. Other distractions that can lead to loss of valuable time for physicians include repetitive activities, email burden, etc. Solutions for “time wasters” recommended in a paper published by group.bmj.com include: developing automated patient education handouts to avoid repetitive activities, creating ‘quick text’ for frequently used phrases in email or in electronic medical records, organizing the desk, office, communication and electronic and paper files.
Proper use of the electronic medical record (EMR) system: Proper EMR use also improves time management. Physicians should be knowledgeable about the system’s automatic ‘quick text’ features so that they can efficiently document medical information during the patient encounter. Voice recognition software can also enhance productivity. Other new technologies such as cloud backup systems for important files and articles, synchronized calendars and task lists can also improve time management and help physicians get more time for patient care.
Improve communication skills: Regardless of visit length, physicians must develop strategies to enhance the quality of care in the available time. Effective patient-physician communication impacts patient satisfaction and outcomes, including medication adherence. Listening and asking patient centered questions may require more time but this can be addressed by establishing the agenda for visit at the outset, paying attention to the patient’s emotional concerns, and listening actively.
Team-based care: A team approach may help physician manage their time more effectively to focus on their patients. This strategy involves the efficient use of support staff to reinforce the physician’s message and understand patients’ needs. In team-based care, different players treat a patient and each member of the team must work with the others to drive optimal care outcomes. Key tasks in an outpatient encounter include data gathering, physical examination and synthesis of data, medical decision-making, and patient education and plan-of-care implementation. The data gathering, including documenting the patient’s complaints and gathering more information through questioning, can be handled by clinical assistants. The physician can develop protocols and templates based on specific patient complaints and chronic conditions. Team based care can save time and improve patient outcomes and practice efficiency.
Outsource medical transcription: EHR documentation is tedious as it involves too much time doing data entry which takes away from direct eye contact with patients. A time and motion study to examine how physicians allocate their time during a typical clinical day in ambulatory care practice. The American Medical Association reported on the key study findings, which are as follows:
- For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours are spent on EHR and desk work within the clinic day.
- Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.

The most practical option to reduce the EHR documentation burden is to outsource medical transcription. With an experienced medical transcription service provider handling the task, physicians can be assured of accurate, integrated and complete digital patient medical records from their notes. With the right support, physicians can spend more time on patient care and also preserve the integrity of the medical record.

More time with patients translates to better care, increased revenue and improved practice efficiency.

MTS has extensive experience providing medical transcription services for various medical specialties. Our HIPAA compliant medical transcription company provides accurate and timely EHR documentation solutions, allowing physicians and their staff to focus on patient care.

What Are The Main Parts Of Operative Notes?

12-December-2022 Julie Clements Medical Transcription

Operative Notes

Transcribing operative notes, surgical reports, and other surgical documentation requires meticulous attention to detail.

Operative notes are the detailed and comprehensive documentation of a surgical procedure that is recorded by the surgical team. These notes are typically dictated by the primary surgeon or other authorized medical personnel who were present during the surgery and usually dictated or entered electronically into the patient’s medical record. Given the importance of ensuring quality surgical notes, billing requirements, medicolegal concerns, and other secondary applications of operative notes, effective operative note documentation is critical. Surgeons can ensure accurate EHR documentation with the help of a competent medical transcription service organization.

What Is an Operative Note?

The operative note is an essential part of the medical record and provides a detailed account of the surgical procedure performed, including all pertinent information such as the specific steps taken, instruments used, findings, and outcomes. It is the most significant piece of information in the surgical chart.

It serves as the formal record of what happened in the operating room. It must back up the patient’s need for treatment, detail each step of the surgery, and show the results of the operation. The operative report is the most common document used to support claims for payment to the surgeon, surgical team, and facility. Operative report documentation is also important for auditors and payers to confirm that the supporting paperwork matches all of the codes listed on the claim.

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Main Components of Operative Notes

Operative notes contain the following information:

Pre-operative information: This includes the patient’s name, age, medical history, and relevant pre-operative assessments, such as lab results, imaging findings, and other pertinent information that may have impacted the surgical procedure.

The History/Indications for Operation section explains why the surgery is necessary and, if appropriate, what happened before it. The surgeon provides information about the patient’s past medical history relevant to the procedure, their family history relevant to the procedure, previous or unsuccessful therapies, how the disease or injury occurred, when it occurred, and for how long.

Heading: The operative report’s heading includes the following information:
Facility Information – the facility’s name, address, and the patient’s unique medical record number.
Patient information – the patient’s legal name, date of birth, age, and gender (certain processes are age- and gender specific).
Date of service – The date on which the operation was done.
Information about the surgical team – the primary surgeon’s name and the names of any co-surgeons, residents, or surgical assistants, and the anesthesiologist’s or CRNA’s name.
Surgical procedure details: The operative notes provide a detailed description of the surgical procedures performed, including the type of surgery, the type of anesthesia used, the specific surgical technique or approach used including closure technique, the names and dosages of medications administered, any modifications or deviations from the standard procedure, the use of any implants or specialized equipment (such as a microscope, robotic arms, etc.); complications, and estimated blood loss.
Instruments and equipment used: The operative notes list the names of the surgical instruments, devices, and equipment used during the procedure, as well as any complications or issues encountered with the equipment.
All eligible diagnoses are listed to show medical need for pre- and post-operative care.
Body: This section contains the following details:
- Description of the Procedure(s) – This part should include a description of every step of the procedure, from preparation to dressing and closure, even if it is already noted in the Heading. If the surgery was performed bilaterally, both sides must be documented here. The proper side must be recorded if something is done unilaterally.
- The following elements are also recorded: the surgical technique (whether open or endoscopic), the placement of the implants or devices previously listed in the Heading, the use of robotic or microscopic assistance previously listed in the Heading, any specimens collected or frozen section procedures performed, intraoperative monitoring or testing, and any surgical procedures performed by another surgeon
- The most crucial section of the operating report is the description of the procedure(s). This is when the fundamental medical coding principle “IF IT’S NOT DOCUMENTED, IT’S NOT DONE,” comes into play. If a technique is not included here, auditors or payers may choose not to reimburse for it or may choose to recover a prior payment for it.
- Coding must come from this part as well as from the Heading’s procedure listings. The heading’s procedures should just serve as a coder’s check list for what to look for in the operative report’s body. The surgeon needs to be contacted for confirmation and potential correction if the coder discovers a procedure is missing, bilateral documentation is missing, or there are any other inconsistencies between the heading and the body.
Findings: Operative notes record any notable findings during the surgery, such as anatomical structures encountered, abnormal or diseased tissue identified, and any unexpected findings that may have influenced the surgical approach or outcomes.
Intraoperative events: Operative notes also document any significant events or incidents that occurred during the surgery, such as bleeding, complications, changes in surgical plans, or unexpected events.
Postoperative care: The operative notes may also include information about postop care instructions, wound closure techniques, drains or catheters placed, and other relevant postoperative procedures or interventions.
Outcome: Operative notes also provide a summary of the surgical outcome, including the status of the patient at the end of the surgery, any postoperative complications or concerns, and the plan for further postoperative care.

General Principles of Operative Notes Documentation

A member of the operating team is required to complete the operative note right away following an operation (either handwritten or typed). All post-operative notes should be included as the most recent entry in the patient’s current medical records, and they should travel with the patient to recovery and subsequently, the ward. It is crucial to ensure that the operation note including the post-operative instructions, are written properly.
The intra-operative findings, including any disease, should be clearly and concisely stated as part of the surgical diagnosis. A reference copy of any photographs taken during the process should be included with the operative note.
All the surgical processes, from the first skin incision through closure, should all be accurately described exactly as they are performed. This could include any pertinent vessel ligations, implants or prostheses used, tissue removals, and alterations in specified anatomical structures.
The closure should be documented along with the material(s) used and the closed layers, such as fascia, fat, and skin. Any intraoperative complications should be accurately reported, together with any specimens obtained and the estimated blood loss (written in mLs) recorded.
To guarantee proper post-operative care, post-operative instructions should be carefully documented to include any specific plans that must be followed after the treatment. This covers any drugs to be administered, whether the patient is able to eat and drink, whether they may be sent home, and any required follow-up activities (including dressing changes or suture removal)
After the operation note has been written, it should be signed, dated, and the signing doctor’s name, grade, and registration number should be included.

Learn more: Four Key Reasons Why Medical Transcription Is Important Today

Like other medical reports, operative report documentation is a significant document in the EHR. These reports, which offer thorough health information about your patients, can be shared with other healthcare professionals and organizations including laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, etc. Partnering with a reputable medical transcription outsourcing company can transform surgeon dictations into correct surgical notes.

We ensure meticulous attention to detail in transcribing operative notes, surgical reports, and other surgical documentation.

How Medical Transcription Services Help Dentists To Have Accurate Medical Records

08-December-2022 Rajeev Rajagopal Medical Transcription

Medical Transcription Services

Given the importance of clinical documentation and record keeping in providing optimal patient care, it is an essential component of practice management. It becomes a serious issue, though, when you have to devote too much of your valuable time to keeping track of your patients’ medical information. Dentists also fit this description. Due to their hectic schedule, dentists may not be able to keep patient records properly updated. Any mistake in dental transcribing could compromise the document’s trustworthiness. To maintain accuracy and guarantee that the records are error-free, dental records documentation can be outsourced to a trustworthy dentistry medical transcription service.

Learn more: Why Dentists Should Choose Medical Transcription over Speech Recognition

Advantages of Using Medical Transcription in Dentistry

The patient record can be used by nursing and other support personnel as a manual for patient care, including warning indications that need to be investigated.
Dental staff, nurses, hospital administrators, and others can devote the majority of their time to caring for patients while doing other tasks effectively in the background. Dental professionals can benefit from outsourcing dental transcription if they are tired of spending countless hours in front of a computer screen tracking reports or patient charts. For instance, if you use periodontics transcription services, you can capture medical notes, reports, and other important information using audio dictation.
Another significant advantage of employing a medical transcription provider is the time and money savings ensured. With the aid of a smartphone app, a nurse or other healthcare worker simply needs to capture voice notes to be immediately prepared to switch to other work.
Billing and coding staff might use medical records that are prepared systematically to simplify insurance settlement. Accurate transcription is necessary to speed up the payment of insurance claims, whether it be periodontics transcription or any other dental transcription services.
Legal requirements in some situations make keeping medical records vital. In the event of legal disputes, these records can be an invaluable asset. It becomes simple to accomplish so with the help of medical transcribing services.

Through the dental record, dentists can communicate with patients and other healthcare professionals who could be involved in overseeing the patient’s treatment. Providers who are unfamiliar with the patient can learn about their dental history and experiences from the complete and correct records.

Consider Some of the Following Steps to Document Dental Records

Every setting in a dental practice should follow the same charting procedures, and the dentist is always responsible for making sure the charts are accurate. For chart entries, take into account the SOAP (Subjective, Objective, Assessment, and Plan) method for better clarity and transparency.
Always be careful about what information you are entering in the dental record, especially if the remarks are complex. A court of law might read your notes aloud, so keep that in mind. Make sure they accurately depict the events that occurred. Therefore, a good rule of thumb is to first outline what you intend to write in the record before entering the information in a systematic way into the patient record.
Ideally, documentation should be done either while the patient is still in the office or as soon as possible after they depart.
Each entry in the dental record needs to be legibly written and assigned to a specific person. Even if there is just one dentist entering data into the treatment record, it should be done properly. Most practice management software systems automatically assign the initials of the notation maker. The paper record must be signed/initialed by the team member who made the entry. Irrespective of the format, every entry in the patient’s file needs to be approved by the dentist.
Don’t forget to attach any necessary documentation, such as radiography and informed consent or informed refusal forms. These attachments give the dentist a tool to assess both the immediate and long-term consequences of the treatment given as well as the implications of any aggravating circumstances. The patient’s response and cooperation may also be recalled.
When making changes or additions to earlier records’ notes, be cautious, especially if your software system is about to update or close records.
Attempt to complete treatment notes within 24 hours so that you can answer if you are questioned about the timeliness of any changes to a patient’s record, that the modifications were made “that day” or “on the same day.
The date and time when the delayed entry was added to the chart should be included, together with any adjustments to earlier entries. When confronted with a dental malpractice claim, a board investigation, or a patient complaint regarding the efficacy of your care, never change the record.

To convert dental records into the required format, dentists can get in touch with a reputable medical transcription service. They provide various transcription services, including pathology, orthopedic, and psychiatry transcription, among other medical specialty transcription.

Dos And Don’ts Of Managing Clinical Records [INFOGRAPHIC]

05-December-2022 MTS TEAM Infographics

Medical records are a fundamental element in the provision of patient care. Good clinical records aid – coordination and continuity of care, and informed decision making for patient management. It can also improve availability of data for malpractice litigation. Patient records should be updated at each care episode. Physicians can rely on medical transcription services to maintain a permanent account of a patient’s medical history and more.

A good clinical record will include History, Patient examination, All systems examined, Important findings (such as disease diagnosis and stages) with values of blood pressure, peak flow, etc, Differential diagnosis, Details of any investigations ordered, Details of referral(s) made, Instructions and information given to the patient, including about risks and benefits of proposed treatments, Consent given for proposed investigations, treatments or procedures, Treatment – details of the main doses of drugs, total amount prescribed, and any other therapy organized, Follow-up – arrangements for follow-up tests, future appointments and referrals made, and Progress – the patient’s current condition, side effects, complications, any further consultations, etc. Partnering with a HIPAA compliant medical transcription service organization can ensure the privacy and security of data.

Check out the Infographic Below

Clinical Records

Read our blog on How To Maintain Good Clinical Records