Why Patient Friendly Notes Are Critical For Improving The Patient Provider Relationship

01-December-2022 Julie Clements EHR Transcription

Patient Provider Relationship

The patient-provider relationship has become as the foundation of quality healthcare. The 21^st Century Cures Act gave patients the right access to their electronic health record (EHR). Many studies report that patient access to their medical records can encourage them to collaborate with their provider and become active partners in their own healthcare. While medical transcription services can help physicians ensure accurate and timely EHR documentation, writing patient friendly notes is critical for building trust and knowledge, and improving the patient provider relationship. Also, physician language in patient health records can impact the quality of care that patients receive across the continuum of care.

Benefits of Patient Access to the EHR

Giving patients rapid and convenient to their personal health information can get patients and physicians on the same page. According to the Cures Act Final Rule, providers must be able to make eight types of information available to all patients, free of charge:

Consultation notes
Discharge summary notes
History and physical
Imaging narratives
Laboratory report narratives
Pathology report narratives
Procedure notes
Progress notes

So, patients now have electronic access to a broad spectrum of their medical data as well as physician notes.

Many studies have found that open notes drive better outcomes. A May 2021 Journal of General Internal Medicine study reported that 50 percent of clinicians who first tried clinical notes found that their patients took better care of themselves when given access. About three-quarters of providers said they saw better patient empowerment (patientengagementhit).

Trust, knowledge, regard, and loyalty are the key elements of the physician-patient relationship. Importantly, reports say that the patient-provider relationship is crucial to quality care. Sharing visit notes can contributes to patient-provider satisfaction in many ways:

Improved patient education
Improved patient engagement and empowerment
Patients understand their care plans better and become active partners in their care
Access to healthcare visits, test results, and treatment history empowers patients to better manage their own health
Improves medication adherence and follow up on doctor visits
Supports improved chronic care management
Can lead to medical error detection and correction, contributing to improved patient safety
Improves patient outcomes

However, the success of the Open Notes strategy depends on writing “good” open notes for a positive patient experience.

What are “Good” Open Notes?

A positive patient-provider relationship depends on empathy, strong communication, and shared decision-making. Open clinical notes that are empathic, informative, and rely on objective clinical information are most likely to yield a good patient experience according to PatientEngagementHIT.

The American Academy of Family Physicians (AAFP) observes that although the new law does not require physicians to change their note-writing style, some small modifications can be helpful, particularly when documenting potentially sensitive topics such as mental health, obesity, substance use disorder, sexual history, or spousal abuse. The AAFP says that for notes to be patient-friendly, they should ideally have the following four features:

Transparency: The note should reflect the physician’s communication with the patient in the office. “There should be no surprises”, notes the AAFP.
Minimal use of jargon and abbreviations: It’s likely that patients will misinterpret complicated medical terms. Such terms should be briefly defined or simplified. Here are a few examples of such terms: blood profile – series of blood tests; bradycardia – slow heartbeat; idiopathic – of unknown cause; subcutaneous under the skin, and prognosis – outlook, probable outcomes. Derogatory slang in patient notes can also have an impact on patients and family members. A 2021 JAMA network article noted that physicians should increase their awareness of stigmatizing language in patient records to ensure that their notes are informative and respectful.
Highlight both the patient’s problems and the patient’s strengths and achievements: This is especially important in mental health records, as it will give patients a proper perspective of their illness as they deal with difficult behavioral changes.
Describe behaviors and not label the patient or be judgmental: Using positive rather than judgemental language is important. The JAMA network study found that positive language was included in patient notes more often and more explicitly, including: (1) direct compliments, (2) expressions of approval, (3) expression of the physician’s own positive feelings toward the patient, (4) minimization of blame, (5) personalization, and (6) highlighting patient authority for their own decisions. The researchers noted that negative language in patient noted could potentially transmit bias and affect the quality of care that patients subsequently receive.

How a Medical Transcription Company can Help

“Over the past decade, this practice innovation-known as ‘open notes’- has spread widely, and today more than 50 million patients in the United States are offered access to their clinical notes,” observed OpenNotes leaders in the Annals of Internal Medicine. With healthcare challenges, such as an aging population, an increasing number of patients with chronic diseases and comorbidities, and the outbreak of infectious diseases like COVID-19, physicians are under constant pressure and time constraints to manage a higher workload. By enabling patients to become actively involved in their own care, providers can improve their relationship with them and provide better outcomes. Medical transcription outsourcing can play an important role in the open notes revolution by ensuring timely, error-free patient records, allowing providers focus on care, and freeing up internal resources for other core tasks.

Also read: Sharing Notes with Patients – What Physicians Need to Know

Why Is Patient Education Important In Healthcare?

28-November-2022 Rajeev Rajagopal Medical Transcription

Healthcare

Ignorance may be bliss sometimes, but not when it comes to patients. Patients should be educated to be proactive about managing their health. Patient education empowers patients to participate in their own health care and make lifestyle changes to prevent or manage illnesses. Physicians can leverage electronic health records (EHRs) and medical transcription services to provide patients with detailed and accurate information about their health and health care. Other methods physicians can use to reach out to patients include websites, text messaging, and email.

The American Academy of Family Physicians (AAFP defines patient education as “the process of influencing patient behavior and producing the changes in knowledge, attitudes and skills necessary to maintain or improve health”. When patients don’t have proper health literacy-the ability to understand, engage, and act upon health information-it can negatively impact health. In today’s world, with so much of medical misinformation doing the rounds on social media, educating patients and promoting trustworthy health information is paramount.

Reasons why Patient Education is Important

To provide patient education, healthcare providers need to understand the reasons why it is so crucial:

Supports engagement in pre- and post-care management: Providers can educate patients on preparing for a particular procedure, ensuring they have completed any necessary tasks. This includes getting the necessary lab work, quitting smoking, adjusting their medications, and dietary advice. Post-care management strategies help patients take care of themselves after a procedure and includes advice on recovery in terms of treatment, follow-up, medication, diet, and home care. When patients are scheduled for surgery, they also need to be educated about treatment options and the risks and benefits of the procedure and its possible side effects. Studies have found that when people are well-informed about their treatment options, they enjoy a better outcome and are more satisfied with their results.
Promotes prevention or management of chronic diseases: Chronic conditions such as heart disease, cancer, stroke, lung disease and injuries are the leading cause of death in the United States. It is important to educate patients on importance of leading a healthy lifestyle to prevent chronic disease. Patient education also helps patients self-manage chronic disease. Such education is vital as the management of chronic diseases usually happens at home. When patients are knowledgeable about their condition, it will help them take the recommended steps to stay well and experience better outcomes. For instance, teaching patients with diabetes about how to measure their blood sugars, what to do if they feel a blood sugar drop, how to use continuous glucose monitors, and diet or exercise plans, can help them better manage their condition.
Provides information about preventive care: Providers should educate patients about the importance of timely screening and other preventive measures like getting the annual flu shot. Patient adherence to preventive care services is critical to prevent a chronic or acute illness. It can also help detect such illness early, which is important for better success with treatment.
Addresses patient-held medical misinformation: Educating patients is important to combat medical misinformation Even while patients trust their providers, they often turn to other sources to get medical information. For instance, people usually turn to Google to find information about medical conditions and their signs and symptoms and more. A new WHO review found that incorrect interpretations of health information, which increase during outbreaks and disasters, often negatively impact people’s mental health and increase vaccine hesitancy, and can delay the provision of health care (www.who.int)

While government health agencies, professional organizations, and patient advocacy groups may provide accurate information, there are many sources, including social media, that do not. Patient-held medical misinformation can have serious health consequences. Health care professionals need to invest time to hear out medical misinformation that patients describe, explain the facts, and work with them to ensure that they seek information only from credible sources.

Key Patient Education Strategies

Good patient education depends on using the strategies that are right for each patient. Here are various tools that healthcare providers can use to educate patients:

Brochures and printed booklets in relevant languages
Posters and charts
PowerPoint presentations
Podcasts
YouTube videos
Models or props
Group classes
Peer educators

As response to these measures may vary from person to person, providers can consider using a mixed approach that takes account of patient literacy levels and other individual factors. Moreover, these strategies will work best when combined with patient teach-back – checking patients’ understanding by asking them to describe in their own words what they need to know or do about their health.

Best Practices for Patient Education

Healthcare organizations should develop a robust patient education program and do the following:

Educate patients at every encounter from admission to discharge.
Involve family
Consider patients’ strengths and weaknesses
Listen to the patient and correct any misinformation.
Use simple strategies and visual aids that patients can understand.
Ask patients to repeat their self-care instructions and how they will explain their disease or treatment to their loved one.
Provide clear instructions on medications, including administration, and make sure patients understand when to refill medications.
Tell patients about signs and symptoms of their condition that will require immediate attention.

Family physicians or primary care physicians are specially qualified to provide comprehensive care for people of all ages. They treat most ailments and provide routine health screenings and counseling to encourage and support changes in lifestyle with the aim to prevent illnesses. The basis of family medicine is an ongoing, personal patient-physician relationship, which makes them ideally positioned to provide patient education. Educating patients is an ongoing process and you need to delegate more responsibilities to support staff focused on patient education. A family medical transcription company can help provider manage medical documentation and ensure that all interactions with patients are properly documented.

How To Maintain Good Clinical Records

24-November-2022 MTS TEAM Medical Transcription Outsourcing

Clinical Records

Good clinical records are essential for the delivery of quality healthcare, to maintain continuity of care, and to share information between different healthcare professionals. Once created, electronic medical records should be updated at each care episode, allowing any member of the care team to reconstruct a consultation or patient contact. Today, physicians rely on medical transcription services to maintain a permanent account of a patient’s medical history and more.

Importance of Good Clinical Records

Medical records are a fundamental element in the provision of patient care. In addition to structured data with variable name and a value (such as height, weight and blood pressure, etc) and stages of a disease diagnosis, medical records include unstructured data in EHR free-form text fields, discharge summaries, progress notes, physician clinical notes, lab reports, photographs, faxed records and printouts, medical images, data on patients’ socioeconomic status verbal correspondence between health professionals.

As listed by www.medicalprotection.org, good clinical records will include:

History – relevant to the condition including all answers to direct questions
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
Progress – the patient’s current condition, side effects, complications, any further consultations, etc.

Clinical records need to be correctly dated and have all the information that the healthcare team needs to make informed decisions about the patient’s care. Poor quality documentation or incomplete medical records could have adverse consequences for the physician as well as the patient such as:

Mislead healthcare professionals and patients
Lead to wrong medical decisions
Increase medico-legal issues
Lead to unnecessary repeat testing or other investigations
Prolonged hospital stay
Compromise patient care
Lead to adverse events such as medication side effects, injury, psychological harm or trauma, or death
Lost revenue/reimbursement

Maintaining Good Clinical Records – Dos and Don’ts

Clinical records are the formal chronological documentation of health care and medical treatment provided to the patient. The health record must be clear, accurate, legible and written in a professional manner and include of the above-mentioned components. Here are the dos and don’ts of clinical documentation:

Dos

Maintain timed entries: All entries should be legible, complete, timed, and have a dated signature. Best practice is to make entries as soon as possible after the event before the relevant staff member goes off duty. Delays, if any, should be documented, including the time of the event and reasons for the delay.
Record any noncompliance: Physicians should document a patient’s failure to take medication, get recommended tests, keep an appointment with a specialist, or other actions that a patient complies with fails to comply with that cause or increase the risk of injury or delay resolving a medical condition.
Document communications and informed consent: Physicians should effectively document patient phone calls including actions taken in response to the call. It is also necessary to make document consultations with other members of the patient’s healthcare team as well as discussions related to informed consent with patients and their family.

Don’ts

Avoid using abbreviations: Confusing abbreviations can cause problems with patient care. For instance, MS can mean morphine sulfate or magnesium sulfate. Avoid ambiguity by spelling out the word. On the other hand, it is acceptable to use commonly recognized acronyms and abbreviations in the medical record, e. g., HIV, GA, BMI, a.m., p.m., etc.
Don’t use comments that may seem offensive: Patients have a right to access their records and an insensitive, personal or offensive remark can damage your relationship with your patient and damage your credibility, especially if the record is used in evidence. Make objective comments. For instance, rather than referring to a patient as abusing drugs, report that the patient has demonstrated ‘drug-seeking behavior.
Avoid indiscriminate use of deletion or corrections: Never change the clinical information/documentation after final signature. if a mistake is made in a medical record entry, follow proper error correction procedures. All deletions or alterations should be trackable back to the specific person, giving the person’s name, time and date.

Good clinical records are valuable to provide quality care, to evaluate the quality of healthcare services, and for malpractice litigation. Keeping quality documentation safe is essential for security maintenance. For instance, partnering with a HIPAA compliant medical transcription service organization can ensure the privacy and security of data to meet HIPAA requirements. Maintaining clarity, accuracy, and timeliness in medical keeping is also easier with medical transcription outsourcing.

View our infographic on Dos And Don’ts Of Managing Clinical Records [INFOGRAPHIC]

The Role Of Mobile Technology In Boosting Patient Engagement

21-November-2022 Julie Clements Medical Transcription

Mobile Technology

Mobile health (mhealth) technology proved its worth during the COVID-19 pandemic and is continuing to be vital tool for care providers to connect with patients. The World Health Organization (WHO) defines mobile Health (mHealth) as “medical and public health practice supported by mobile devices, such as mobile phones, personal digital assistants, wireless devices, and patient monitoring devices.” The growing use of smartphones and other mobile devices is driving digital patient engagement and mhealth. With new rules allowing patients access to their clinical notes, test results and other medical data through online portals, medical transcription outsourcing is helping healthcare providers maintain accurate and timely electronic medical records.

Digital patient engagement incorporates digital tools to allow physicians to engage and empower patients and offer various medical and educational resources, reducing the need for physical visits to a hospital or healthcare facility. According to IT major Accenture, 54% of patients want communicate with healthcare providers using their smartphones.

The global mHealth market size, which was valued at USD 50.7 billion in 2021, is expected to expand at a compound annual growth rate (CAGR) of 11.0% from 2022 to 2030, according to a Grand View Research report. The report identifies the key market drivers as:

Rising focus on improving personal health and fitness using smart devices and wearables
Increasing accessibility of the internet and smartphones
Increased public awareness about mhealth technology
shift from conventional healthcare practices to patient-centric and preventive approaches
increasing use of smartphones among the adult population and teenagers
Growing adoption of mHealth technology and platforms by physicians and patients, and
Rising use of mobile health apps for remote patient monitoring

Government commitment to digital health and the positive attitude of providers towards real-time patient care are other factors fueling the adoption of mhealth technology.

How Mobile Apps Support Patient Engagement

Patient engagement improves health outcomes by urging people to get actively involved in their health and supporting informed decision making by both the patients and healthcare providers. Mobile technology has taken patient engagement to the next level.

Breaks down barriers to connectivity: The healthcare industry is facing severe staffing shortages. Severe nursing shortage affects patient care and outcomes significantly, including disruptions to essential services. With mobile technology, providers can connect seamlessly with each other as well as with patients and provide timely care. Mobile health technologies enable patients to find health care providers with their reach and also quickly send secure messages and schedule appointments. Messaging applications, such as Short Message Service (SMS) and Multimedia Message Service (MMS) are an effective, easy and inexpensive option for providers to send healthcare appointment reminders.

Integrates with wearables: Wearable devices such as smartwatches, smart glasses, and other fitness trackers are worn on the body to track the person’s health. They store personal health information, record vital signs, calculate and monitor calories, schedule reminders for taking medications, and record physical activity such as daily step count. Today, smartwatches and other devices seamlessly integrate with mobile health apps and their use is steadily increasing.

Provides access to telehealth services: Mobile devices are an easy way to connect patients to Telehealth surged during COVID-19 and kept care providers in touch with their patients when physical office visits were restricted. In August 2021, Google reported that 90% of physicians use telehealth services, compared to just 32% before the pandemic. Pew Research Center found that up to 85% of American adults own a smartphone, up from 81% in 2019, which makes mobile an ideal option for video meetings with physicians. With e-health or mhealth, patients can get primary care for many conditions as well as advice to self-manage their health. Telehealth services include:
- Virtual visits to see a physician, mental health counselor or a nurse. Online video or phone chats are used to assess and treat minor conditions, including migraines, skin conditions, diabetes, depression, anxiety, colds, coughs and COVID-19.
- Remote monitoring: Mobile devices can be used to send data generated by wearable devices. Provider or nurse practitioner can use mobile apps to prescribe drugs or reminders to take drugs, do exercise, etc.

Supports access to and use of patient portals: According to data from the Health Information National Trends Survey (HINTS), nearly four in 10 patient portal users accessed their portal through a smartphone health app in 2020. Mobile patient portal apps allow patients to access their medical histories and care plans. These apps track medications and allergies allow users to review and update their medications. Patient portal apps boost convenience for patients with digital bill payment capabilities. Patients can complete pre-visit assessments before they arrive at practice, thereby cutting down the amount of time they need to spend in the clinic.

PatientEngagementHIT references Amar Shah, MD, as saying that mobilizing the patient portal significantly improved patient engagement and activation rates at the family practice he owns.

“Getting notifications directly on their phone kept the patients more engaged and kept them really logging into the app to see what messages we were sending out to them and what updates we were giving them,” said Shah.

Apple Health Records for iOS devices and CommonHealth for Android devices offers patients the option to download their patient portal onto a centralized mobile health record

Advanced mHealth initiatives are driving robust patient engagement and satisfaction. Engaging patients using mobile technology can improve prevention, treatment, and follow-up, resulting in fewer readmissions, healthier lifestyles and better patient outcomes. Outsourced medical transcription services can ensure accurate documentation of all types of reports, allowing physicians to focus on providing the best of telehealth and in-person treatment.

Documentation Tips To Get Clinical Notes On Time

17-November-2022 Rajeev Rajagopal Medical Transcription

Documentation Tips

Reviewing accurate and current medical records enables clinicians to skip repetitive patient questions, initiate treatment promptly, and minimize the risk of errors at all costs. Not only is it crucial for your healthcare facility’s operations and care, but it is also a key part of billing insurance companies for the cost of the care provided. This is why it is a practical decision to invest in a medical transcription service to create consistent and accurate documentation of recorded material. It is also useful for attorneys to quickly identify a case’s advantages and disadvantages.

Significance of Accurate Medical Documentation

According to the Journal of AHIMA, the main goal of documentation in hospitals is to guarantee that patients receive the treatment they require by providing medical professionals the data they need to make informed decisions. A patient is likely to interact with many medical staff members while undergoing treatment, which include doctors of different specialties and nurses. If a patient needs ongoing or follow-up care, he/she may also visit a provider at another facility.

Medical records may include imagery from technicians that the patient may not even have spoken to and results of lab tests. In addition to the treatments that have previously been given, the patient’s file should also include a diagnosis and treatment strategy. 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. Additionally, it aids in avoiding improper medication administration. The treatment strategy aids in ensuring that the patient receives the additional attention required to make a full recovery or manage an ongoing condition.

Learn more: Medical Transcription Improves Medical Documentation in Hospitals

Effective Medical Documentation Tips:

1. Utilize the talents of your team: Not everything needs to be documented by you; strategically incorporating your team can save hours. A nurse or medical assistant, for instance, can record allergies, review prescriptions, and record patient outcomes. You can easily check the accuracy of this information before signing the memo.

2. Establishing professional norms: The first step in improving clinical documentation is for a practice to establish note-taking policies that adhere to accepted industry standards. In a recent paper, the American College of Physicians (ACP) outlined several methods that healthcare professionals can use to enhance their documentation. According to the authors, practices should establish policies based on “professional norms determined by consensus and specific to each specialization.” When creating practice guidelines, they advised doctors to put clarity, conciseness, and the needs of other readers first.

3. Finish up the bulk of the paperwork in the space: Summarize what you’ve said to the patient while taking or dictating notes while you discuss their medical history or treatment plan. Speaking your dictation aloud is effective and can interest the patient while enhancing understanding and ensuring accuracy. Many healthcare professionals have discovered that dictating clinical notes during patient visits has significantly streamlined their recording process.

4. Develop peer-to-peer support networks: It’s a good idea to designate a physician leader to lead documentation improvements in order to lessen dependency on EHR vendors or outside training. A peer-to-peer help mechanism will be established once there is a staff member who is knowledgeable about optimal documentation techniques. This person must be committed to the mission and knowledgeable about emerging note-taking techniques. He or she will become the go-to person for queries from doctors or support personnel and can assist the office to be on the same page with documentation.

5. Know the requirements for E/M documentation: A thorough system review or comprehensive examination is not necessary for a 99213 level of service. Family doctors who treat Medicare patients utilize this code 61 percent of the time. Save time by following the rules and simply documenting what is required for the present day’s visit in terms of medicine.

6. Employ fundamental EHR features: Examine whether you utilize your EHR’s time-saving features. For example, templates are useful for frequent visits where clinical inquiries are expected. In complicated or dynamic scenarios, manual typing or mobile dictation could be the fastest option. However, if it’s flu season, save time by making a simple template for your influenza vaccine.

7. Don’t strive for perfection: For people who are obsessive “box-checkers” and perfectionists, the EHR can be a huge pile. Consider the documentation requirements and make it straightforward. You don’t have to fill out every category on each visit, and not all boxes need to be checked. Recognize what matters and ignore everything else.

8. Tune the “opus“: Write down whatever information you wish you had but doesn’t exist on a sticky note while you examine previous notes in preparation for the next visit. After a few days, you might start to see certain trends, such as “explain the mechanism of damage” or “register the name of the caregiver.”

9. Monitor yourself: To determine how long it takes to finish a note, set a timer on your watch or smartphone. Set a target to reduce the time you spend documenting each patient after knowing your baseline. Speed shouldn’t be your main priority; taking more time to record appointments with unfamiliar or challenging patients may be beneficial.

Maintaining accurate medical records is essential to lower the risk of malpractice and ensure that the hospital can bill effectively. Accurate documentation ensures that services and treatments can be paid correctly to the patient or insurance provider. Medical dictation transcriptions must be accurate in order to guarantee proper patient care. These records, which are a part of the medical chart, are crucial for billing and payment purposes. For medical practitioners, patients, and insurance companies that analyze medical claims, high-quality transcription is crucial and medical transcription outsourcing services include individualized medical transcribing solutions.

Latest Healthcare Technology Trends For 2023

14-November-2022 MTS TEAM Medical Transcription Company

Healthcare Technology

The medical industry is continually changing, and cutting-edge technologies are enhancing medical procedures. Better patient care and increased patient safety are the results of numerous breakthroughs. The advancements in medical transcribing are an obvious evidence of this change. Physician dictation is converted into text format by medical transcription companies, which then incorporates the documentation into the electronic health record (EHR).

Healthcare technology keeps getting better as 2022 progresses in every way. Due to ground-breaking and developing technologies like artificial intelligence, machine learning, and extended reality, the quality and effectiveness of healthcare will keep improving. Modern hospitals and care facilities rely heavily on legacy infrastructure and software, but it’s necessary to think about how those systems might be integrated with newer technology or eventually replaced by more dependable ones. Improvements in performance, productivity, efficiency, and security should be prioritized without compromising dependability or accessibility.

Top 6 Healthcare Technology Trends

Telemedicine: The emergence of the global coronavirus that led to COVID-19 infections prompted the closure of significant economic sectors and had a significant impact on medical procedures and developments in healthcare technology. In order to avoid spending time in a waiting area with persons who might be infected, many patients cancelled their appointments. They also avoided face-to-face interactions with staff members at the front desk, nurses, and doctors. So, as a way to still allow doctors to see patients, although in a restricted capacity, telehealth usage increased. Telemedicine will increasingly be used, according to experts. Healthcare Dive reported that between 2020 and 2023, the cost of medical services incorporating telehealth might increase by 265%, from $29 billion to $106 billion.

Monitoring Remote Patients: The capacity to remotely monitor your patients is a crucial technological area to keep in mind. Digital health solutions will undoubtedly enhance patient outcomes in the future as the healthcare sector continues to swiftly evolve. It will be considerably simpler to attach a heart monitor to a patient in 2023 for an at-home study as opposed to keeping him in the hospital for several days. From the comfort of their workplace, healthcare professionals can quickly view the vital statistics of their patients who are still at home.

Use of Big Data: Big Data usage is a significant advance for healthcare. Big Data has revolutionized how information is analyzed. Big data can be very helpful in improvising the patient’s therapy and lowering the cost of their diagnostics. Utilizing current medications and available treatments, advanced data mining and analysis techniques of Big Data could help treat rare diseases. A healthier life would result from the complex computation employing big data, which would also aid in the analysis of the patient’s earlier and current data.

Role of AI in Healthcare: It’s no secret that artificial intelligence is currently revolutionizing a wide range of industries, including healthcare. Artificial intelligence may be used by a corporation to pre-qualify you for a loan or by your bank if it is short on human customer service agents when you call them. AI is already being used in medicine to expedite medical billing and revenue collection. Because artificial intelligence can quickly review massive amounts of unstructured patient data and establish pertinent connections for healthcare businesses, these trends in healthcare technology are made possible. According to Insider Intelligence, administrative duties in a medical office, such as preauthorizing insurance and maintaining patient information, can be automated by artificial intelligence (AI). AI is also capable of analyzing data from patient gadgets, including glucose monitors and smartwatches, and keeping track of the specifics that humans would be unable to understand in real time.

Wearable Medical Devices: IoT has significantly impacted and enhanced the healthcare industry with innovations like wearable implant devices that track patient runtime data on device apps for vital healthcare trending needs. Patients can utilize it for health monitoring in the healthcare sector. With the advancement of technology, many IoT devices are becoming more affordable and accessible to the general public, which will significantly increase the value of health observations. Wearable IoT devices have a favorable impact on people’s health and are now essential to preventive healthcare. These wearable technology-powered devices offer customers insights into their daily to several months’ worth of activity. As a result, their products have assisted users in keeping track of and managing their health and staying in shape. Monitoring daily health records and accurately diagnosing health trends in real time has become convenient and user-friendly, thanks to the intelligent integration of smartphone apps and wearables.

Accounting for Security and Technology Costs: The usage of software and healthcare technology necessitates the installation of monitoring systems, such as firewalls and anti-malware software, to safeguard these systems. You might need to adapt your spending plan to take into account heightened security needs. It’s reasonable to expect that in 2023, malicious hackers will try to access your data and steal private patient information that you must maintain securely to abide by the Health Insurance Portability and Accountability Act of 1996. In order to ensure that you are taking the proper steps to secure your network and uphold patient privacy, you might need to speak with computer security experts.

Learn more:

Four Key Reasons Why Medical Transcription Is Important Today

The healthcare sector is constantly seeking ways to boost productivity. There is no denying that technology and computers have altered medical transcription on the whole. Advanced technology is used by trustworthy medical transcription companies to help create reliable medical records. To provide future specialists with high-quality care education and information, medical institutions have been consistently modifying and developing their healthcare trends. Since the pandemic, the tech sector has introduced effective and HIPAA-compliant methods for thorough, precise, and less time-consuming examinations, elevating the trends in medical services.

How To Finish Patient Visit Documentation In Time [INFOGRAPHIC]

10-November-2022 Julie Clements Infographics

Even though EHRs have made charting more complete and reliable, it is also time-consuming for providers. To ensure proper documentation along with provision of quality care, and to prevent stress and burnout, practices can consider optimizing systems and processes. Medical records contain diverse details such as – patient history, clinical findings, diagnostic test results, preoperative care, operative notes and discharge summaries. Accurate and on-time patient documentation is a major challenge for healthcare providers in most specialties, especially with the move from paper-based charting to electronic health records (EHRs). An experienced medical transcription service company can provide inclusive support for medical record creation and maintenance. It is also important to follow best practices to help clinicians complete charting in time.

Medical transcription outsourcing can ensure timely, accurate, and complete notes as you focus on your patients. Family practice medical transcription services can ensure that all clinicians engaged in the patient’s care have access to accurate, up-to-date, and complete information.

Check out the Infographic Below

Patient Visit Documentation

Read our blog on Falling Behind On Patient Documentation? How To Complete It In Time

What Are The Different Parts Of A Medical Consultation Report?

07-November-2022 Rajeev Rajagopal Medical Transcription

Medical Consultation Report

When a doctor refers a patient to another doctor, they typically receive an order for a consultation report. The consulting doctor is an expert in a field unrelated to the one the other doctor specializes in, necessitating the need for a second opinion in the patient’s case. The patient’s condition or disorder is briefly described in the consultation report, and if the consultation requires it, an exam is included as well. The strategic plan the doctor would want to implement to treat the patient’s ailment will be discussed at the conclusion of the session. Experts from a medical transcription service transcribe consultation reports into the format specified by the doctors.

Purpose of Consultation Reports

Reports from consultations are utilized to outline the patient’s past experiences as well as the main justification for receiving a more effective treatment. A concise report will explain the patient’s condition to the additional doctor. In hospitals, such as an emergency room, consultation reports are common when a primary care physician provides the initial diagnosis and refers the patient to a specialist. A doctor and a patient may feel more at ease and confident after having another person assess the situation. It also creates opportunity for research into additional medical specialties and patient treatment choices.

Specifications in a Consultation Report

A consultation report will begin by including some specific details about the report and patient – their demographics, the date, and the doctors that referred them. More fundamental details such a patient’s ID number and birthdate are also included. A thorough summary of the patient’s present problems will follow the succinct statement outlining the rationale for the consultation.

The doctor will list to the patient’s medical and personal histories so that they can be reviewed and used to help make a diagnosis. This section will also include one or more of the following:

Medical History: Describe any current or former medical issues, surgeries, and other relevant information.
Allergies: Let the doctor know if the patient has any pharmaceutical allergies.
Medication: Which medications the patient is currently taking, as well as their dosage.
Personal history: Specify whether the patient uses drugs, smokes, or drinks.

This information may occasionally be crucial to the treatments that doctors may be considering as well as the medicines that they may prescribe, if necessary.

Learn more: Consultation Reports in Medical Transcription

Tips to Write a Consultation Report

Type the header of the report or the letter’s address fields. The consulting physician, the referring doctor, the date of the consultation, and the patient’s identifying information will all be listed on these.
The headings “Patient Identification” and “Reason for Referral” or a brief introduction providing this information should be at the beginning of the report or body of the letter. For instance, “The patient is a 32-year-old diabetic woman who was referred for breathlessness.”
Explain the patient’s past. Several titles should be used, such as “History of Present Illness,” “Past Medical History,” “Past Surgical History,” “Medications,” “Allergies,” “Family History,” “Social History,” and “Review of Systems.” List other subheadings for the body’s systems under “Review of Systems,” such as “head,” “eyes,” “ears, nose, and throat,” “respiratory,” “cardiac,” “gastrointestinal,” and “endocrine,” and any relevant symptoms that the patient has.
Under “Physical Examination,” describe the patient’s examination. General Appearance, Head, Eyes, Ears, Nose, and Throat, Neck, Lungs, Heart, Abdomen, Extremities, Skin, Neurologic, and any others that may be applicable may be subheadings in this section. The subheading for the consultant’s area of expertise will probably be more in-depth than the others. A doctor may also decide to exclude information if it is not necessary for the consultation. An orthopedist may not perform an ear exam on a patient who has been seen for a potential leg fracture, for instance.
Underneath the titles “Laboratory Studies” and “Diagnostic Studies,” describe any relevant test results that are available for evaluation. List particular test results together with a statement about whether they fall within acceptable ranges. The outcomes of any previous imaging procedures, such as X-rays or magnetic resonance imaging, may also be included.
To give a qualified assessment of the patient’s condition based on the patient’s history, physical examination, and lab results, use the headings “Assessment” or “Impression.” The consultant’s professional judgement will be in accordance with his area of expertise, considering any additional ailments the patient may have. A consultant may provide a likely diagnosis or a range of alternatives. For instance, a consultant allergist might need to determine whether a patient’s skin rash is actually the result of an underlying skin problem rather than a food allergy.
Under “Plan” or “Recommendations,” describe the measures necessary to treat the patient’s condition. Considering the previous example in Step 6, the allergist might request food sensitivity testing, advise the referring doctor to request it, or offer a subsequent referral to a dermatologist. If more consultations with the consulting doctor are required, it should be stated in this area. Dermatology transcription service can be used to enter your notes electronically with HIPAA-compliant transmission.
A phrase or paragraph thanking the referring doctor for including the consulting doctor in the patient’s treatment should be included at the conclusion of the consultation report or letter. If necessary, contact information ought to be included in the section. The consultant should state if she will continue to follow the patient in addition to the referring doctor if the report is an in-patient consultation.

Most doctors have their consultation reports transcribed by internal medical transcriptionists or a reliable medical transcription service. The transcriptionist will hear the recordings and then write out the reports using the correct format and headings. The length of consultation reports might range from a few words to many pages, depending on how complicated the issue is, and the doctors will provide the best treatment plan and ensure patient care.

Why Is It Important For Physicians To Share Digital Notes With Patients?

03-November-2022 MTS TEAM Medical Transcription

This is an update to our blog: Sharing Notes with Patients – What Physicians Need to Know

Good medical record keeping is essential for the delivery of quality healthcare and to support communication between different healthcare professionals. With the widespread adoption of electronic health records (EHRs), outsourcing medical transcription is a practical strategy to ensure efficient medical record management. Partnering with an experienced medical transcription company can ensure proper documentation of the medical history of the patient, easing the documentation task for nurses and physicians, improving their workflow efficiency, and allowing them to spend more time with patients.

The use of personal health records (PHRs) has increased with rising mobile device use and improvement in patients’ technical abilities. PHRs are integrated with EHR systems. An April 2021 provision of the 21st Century Cures Act, patients can freely access all of their electronic medical record chart notes. Patients have access to the following parts of the electronic medical record:

consultations
progress notes
discharge summaries
history and physicals
imaging narratives
lab reports
pathology reports
procedure notes

Psychotherapy notes are not subject to disclosure under the Final Rule.

Benefits of Sharing Medical Records with Patients

The American Medical Association (AMA) strongly advocates open notes. Studies have found that shared visit notes, also called open notes, increase transparency in care and also have the potential to enhance provider-patient trust and treatment adherence. The first large-scale survey of patient experiences with a broad range of physicians, nurses, and other clinicians working in practices which shared notes reported that patients considered note reading very important for managing their health and share their notes frequently with others. The study was published in the Journal of Medical Internet Research (JMIR) in 2019.

Let’s dive into the top benefits of sharing medical notes with patients:

Enhances patient’s understanding of their health information: It helps them help better understand their doctor’s recommendations, which will help them take actions required for their health, and/or make appropriate health decisions. For instance, in radiology, a well-formatted report with structured information and clear content display including patient summaries, and infographics, can greatly improve patient understanding and inclusivity.
Reminds patients of what was said at the visit: According to a study from Brown University’s School of Public Health, regardless of their level of educational attainment, patients only remember about 49% of the decisions and recommendations made during discussions with their doctors, and about 15 percent of the information was remembered erroneously or not at all. “As stress of that visit increases, the amount that they remember decreases,” says Catherine DesRoches. Executive Director at OpenNotes. The Brown University study found that prompting helped recall another 36 percent of it. So, seeing their notes can help patients better understand and recall what was discussed at the visit.

· Improves treatment adherence: Sharing notes with patients can help them follow their treatment regimens properly. When patients read their notes and understand why a medication is prescribed, it is more likely that they will take that medication as prescribed. It could also prevent problems like not filling or refilling a prescription, taking the wrong dose, taking a medication at the wrong time, and not recognizing the effects of inappropriate dosing, side effects or drug interactions.

A study published in the Annals of Internal Medicine suggested that that medication adherence improved with shared clinical notes (patientengagementhit.com). With access to their clinician notes:

64% or patients said they better understood why their clinician prescribed a certain medication
62% felt more in control of their medications
57% said they were able to find answers to questions they had about their medications
61% said access to clinician notes made them feel more comfortable taking their medications

The study showed even greater benefits for patients who do not primarily speak English or who have lower health literacy scores. Family members or others could help them review and interpret the key points made in notes in their homes.

· Promotes shared decision-making: In addition to supporting treatment adherence, giving patients access their medical chart improves communication and promotes shared decision making. By reading their medical notes, patients can get a better idea of the physicians’ thinking, the pros and cons of different types of treatment, and the feasibility of medical choices. This will also improve patients’ confidence in managing their health.

Informs patient caregiver: Access to notes by family members and caregivers will help them better collaborate with clinicians and provide better care. Providing access to information about the patient’s diagnoses, test results, and prognosis would allow caregivers to give clinicians insights into the patient’s symptoms or behaviors, needs and preferences, which is important for effective support.
Helps detect errors and improves safety: When patients read their notes, they may detect mistakes that are clinically significant. Among very serious errors identified by patients, the most common were mistakes observed were in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient, and sidedness, according to a JAMA study published in 2020. When patients report these mistakes, it can improve record accuracy and patient engagement in safety.
Increases trust: In the AMA STEPS Forward podcast on sharing clinical notes with patients,” co-founder of OpenNotes Tom Delbanco, MD, said, “Even when patients don’t read their notes, just knowing that the note is available, increases their trust in their provider and in the organization where they’re getting the care”. This is especially important during a health crisis like the COVID-19 pandemic when public trust in physicians and medical science waned.

As open notes are a legal requirement, clinicians should pay attention to the quality of the information and its timeliness. Medical transcription services can play an important role in this context. To motivate patients to use the medical information in their record, reports must also be patient-friendly and jargon-free. For instance, the current drive to create patient-centered, interactive radiology reports provides a unique opportunity for radiologists to understand the needs of patients directly, and for patients to effectively communicate their health information (www.medicaleconomics.com). Radiology transcription services are available to support radiologists in their efforts to provide quality radiology reports for patients and referring providers.

Ways To Speed Up Physical Therapy Documentation

31-October-2022 Julie Clements Physical Therapy Transcription

Physical Therapy

As with all other medical specialties, complete, accurate, and timely documentation is crucial in physical therapy to ensure that patients receive appropriate, efficient, individualized, and high-quality healthcare services. Physical therapists (PTs) also need to keep proper clinical records for defending a medical negligence claim and to ensure appropriate reimbursement. While modern physical therapy electronic medical record (EMR) software is designed to improve the efficiency of documentation, reports say that entering data into these systems is actually a very time-consuming process. The good news is that there are several strategies that PTs can use to speed up documentation during the office visit while ensuring that patients get the attention they deserve. Medical transcription outsourcing is a practical strategy for editing the transcripts generated by the software or handling transcription overflow.

Documentation in Physical Therapy – Key Considerations

Documentation is making entries into the patient’s health record, including the consultation report, initial examination report, progress note, flow sheet, checklist, reexamination report, or summation of care – that identifies the care or services provided and the individual’s response to them. In physical therapy, proper documentation, communication and coordination are critical to ensure that individuals receive appropriate, complete, efficient, person-centered, and high-quality health care services throughout the episode of care.

The key considerations in physical therapy record keeping are:

Proper documentation of elements such as the initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.
Adherence to the different norms and processes of the specific setting, such as regulations of payers, state, local facility, or accrediting organizations.
Real-time, historical account of encounters with patients and clients, which is crucial to provide evidence of care and medical necessity in the event of a malpractice lawsuit.

While documenting effectively is necessary while providing patient and client care, the American Physical Therapy Association (APTA) note that PTs often view documentation as “onerous, irrelevant, and unwarranted”. In fact, documentation is a general concern in the healthcare industry. Several studies have found that many physicians consider medical documentation as burdensome, detracting from face time with patients, and a key cause for burnout. But it doesn’t have to be. There are several ways PTs can speed up documentation.

Strategies to Improve PT Documentation Speed and Accuracy

Here are some ways to ease and speed up physical therapy documentation:

Know how to use the EMR system: If you are a new PT or PT assistant, get familiar with your facility’s EMR software. Learn the fundamentals of the EMR system’s operation, including how and where to input information. Becoming familiar with the software is important to take full advantage of its capabilities, document faster, and focus on the patient rather than typing. With the EMR, you can access all the information you may quickly and it at any time.
Use EMR shortcuts: EMR systems are designed with many shortcuts. For instance, auto text entries allow for free-text to be saved and inserted into a note, saving a considerable amount of time when entering large amounts of text. The auto-text or predictive text feature populates the rest of a phrase when you type out just a few letters. EMRs also provide other easy ways to create a consult note and allow previous visit information (HPI, Exam, Physical Exam, ROS, and Assessment) to be pulled into the note. Users can review lab results and compare them by order date or even view the results as a graph. The easy-to-read dashboard allows access to key information with just a click, including previous labs and image results, medical summaries, alerts, patient documents, and encounters, and the list goes on.
Complete documentation on a daily basis: Systematic medical records documentation is necessary to prevent documentation piling up. Without consistent documentation on a daily basis, you would be left spending hours on unpaid documentation at the end of your long working day. Multitasking would be necessary to document as you are interacting with patients. If you can’t manage this, you can always rely on a medical transcription service provider specialized in physical therapy documentation to complete your notes.
Document only what’s necessary: Thorough documentation is necessary to show why the PT intervention was needed during treatment, provide an indication of the patient’s status and what is included in the plan of care. However, reports say that clinical notes have grown longer and less informative in recent years. Make sure you don’t document superfluous information. Save time by documenting only relevant patient information.
Use custom documentation templates: Developing documentation templates can help PTs save many hours on Advanced EMR systems features flowsheet templates that allow the therapist to populate entire treatment charts with one click and edit them to include only relevant information. PT Progress recommends that PTs use the PRIMER method to save time and write accurate notes. PRIMER is an acronym for: Identify the Problem, Relate to Activity, Instruct the patient, Manage the response, Educate the patient, and Review the plan. Along with documentation templates, the PRIMER method can work with SOAP notes to speed up and enhance the quality of PT documentation (www.ptprogress.com).
Plan the initial evaluation: Point-of-care documentation can save time when the initial evaluation is carefully planned, according to a CoreMedicalGroup blog that references expert views on this matter. By planning for the initial evaluation, you can factor in time for creating reports when the patient is in the clinic to ask questions and provide clarifications. Completing both the Subjective and Objective tabs before leaving the treatment room will save time that would be otherwise be needed to go back and complete these sections at the end of the day.

Using Speech Recognition Technology (SRT) is an effective way to save time on PT documentation. With an SRT-enabled tablet, mobile device or computer, you can dictate patient information get it transformed into text in real time. However, though modern voice recognition technology feature comprehensive medical terminologies, errors can occur in machine-generated documentation. A strategy that combines structured EHR templates with physical therapy medical transcription services can address this issue and ensure accurate and timely PT documentation.