What Is EHR Note Bloat And How Can You Avoid It?

27-October-2022 Rajeev Rajagopal EHR Transcription

EHR

Medical record keeping has evolved over the years. Formerly, physicians dictated their notes and got the spoken reports converted into hand-written or typed notes by a medical transcription service company. With the advent of EHRs, the role of medical transcriptionists changed and they now review and edit the draft EHR reports prepared by physicians, correct mistakes, add clarifications, and improve accuracy. Today, EHR note bloat and cloned notes are a major problem for all physicians, regardless of their medical specialty.

Documenting interactions with patients is essential for healthcare to work. There are many reasons why clinicians maintain clinical documentation:

To help recall what was happening with the patient and what was said and done
To communicate to other clinicians
To defend against allegations of malpractice
To prove that quality care was provided
To engage patients in their care
To get paid for services rendered

The problem is that the perceived requirement to meet regulatory needs with proper and comprehensive documentation has led to lengthy, unclear notes that serve no purpose.

Reasons for EHR Note Bloat

Medical records document the patient’s history. This allows physicians to review past data, and allows information to be shared in an organized way with other providers involved in the patient’s care. Recording patient history and dictating notes requires physicians to be succinct, detailed, and empathetic. In the days of hand-written notes, physicians or their medical transcription company completed preparing the notes after the patient visit.

Note bloat in an EHR system occurs when physician clinical notes contain too much unnecessary information, in most cases, missing or concealing critical or time-sensitive information in the patient’s record.

Today, EHRs require physicians to record a lot of information during the office visit, even as they are performing a physical and speaking to the patient. A Forbes article noted: “As the information is entered into the medical record, the system prompts the doctor on additional questions to ask, physical exams to perform, tests to order, and treatments to consider”. It’s hardly surprising that in place of cohesive and concise notes, EHRs have resulted in the phenomenon called note bloat. The key reasons for note bloat are as follows:

EHR documentation tools: EHR systems offer clinicians various time-saving tools for documentation such as dictation, templated pull-down menus, direct keyboard entry, interfaces with supporting systems, and automatic text generation or copy-paste. All of these result in unnecessary documentation and confusion. Copy and paste saves time, but can cause redundancy and other risks.
Documentation to warrant the patient’s bill to their insurance company: While documenting more information does not contribute anything to patient care, providers who are not knowledgeable about coding requirements, may end up including more clinical data to support higher value billing codes. To decrease documentation burden and note bloat and make code selection more intuitive, CMS has overhauled the rules for office-based Evaluation and Management services.
Meet productivity goals: Paperwork and administrative requirements have increased significantly, leading physicians to include more documentation than necessary using auto population and copy-paste. For example, as a Medscape article points out with diagnosis-related group (DRG) classifications, physicians have to maintain a high case-mix index. Sam Butler, MD, who was Epic’s chief medical officer (CMO), explains that physicians have to prove they have sick patients if they want to get paid.
Fear of litigation: Fear of missing something that could result in litigation is another reason why providers generate long clinical notes. In the event of a lawsuit, all the information can be presented in one place “to demonstrate all Ts were crossed and all Is were dotted”. However, the truth is that, when previously recorded unnecessary and unreviewed peer notes pile up, they will mask the medical findings and the physician can lose the case.

How to Avoid Note Bloat

Note bloat prevents efficient, compliant clinical documentation and can promote higher quality care. Here are some top strategies that experts recommend to avoid note bloat:

Focus on communicating information that is important at that moment: According to a For the Record article, clinical notes should inform the care team what the clinical situation is, provide recommendations and perceptions on a care plan, and why that care plan is the best course of action at that moment. While the patient’s history and previous treatment plans should be considered, the note should focus on what’s happening on that day and what needs to be done next. If a condition has been resolved, this should be mentioned in the note.
Training: EHR documentation training can improve documentation accuracy and also save time, reducing the number of hours physicians spend on entering information into the system. With EHR training for clinicians, practices can not only increased documentation and coding accuracy, but also realize the EHR’s full potential, improve efficiency and productivity, and boost user satisfaction.
Improve template design: Research shows that redesigning the EHR template can improve documentation and reduce note bloat. A study published in the Journal of Hospital Medicine found that a newly designed best practice progress note template for writing daily progress notes considerably improved the quality of EHR notes, decreased their length, and helped clinicians complete notes faster.
Use technology: Computer-assisted physician documentation solutions that employ artificial intelligence and NLP can help physicians and the CDI team to produce effective notes. These technologies can evaluate clinical notes and create data summaries that can the provider identify the relevant items contained within the patient’s chart, and even find out if anything has been miscoded or undercoded.

EHR notes play a key role in helping physicians take important decisions on care plans, codes, and billing, and much more. However, when primary care physicians have to constantly look the computer screen to take notes, it can take away time from interacting with the patient. Family practice medical transcription services are an ideal solution to this problem. With expert support, physicians can focus on the patient, while adhering to documentation principles.

9 Best Tips To Document Radiology Reports [INFOGRAPHIC]

24-October-2022 Julie Clements Infographics

To generate accurate radiology reports, most practices are now considering radiology transcription services from reliable companies. Radiology reports mostly include chronic incidental findings, the diagnosis or differential diagnosis, the clinical implications of radiologic findings, and any chronic findings that need additional workup or surgical intervention, along with recommendations for management. Accurate, error-free reports help physicians to provide quality patient care. With medical transcription outsourcing, skilled transcriptionists also review and edit the transcribed reports generated by speech recognition apps. The radiology report is an important document that helps guide patient care and becomes part of the patient’s permanent clinical record.

Often, radiology reports contain different types of errors such as – typographical errors, serious omissions such as missing tumors and lesions, misinterpretations, and inconsistencies in report formatting and language. A good radiology report will include many details such as patient demographics (patient name, number, date of exam, type of exam), indication for study or clinical history, technique used (study type and modality), description of pertinent findings (positive and negative findings), radiographic diagnosis, timed and dated electronic signature and more. Radiologists need to avoid errors and include all necessary details to ensure that the radiology report is reliable and accurate. Well-crafted, optimized radiology reports facilitate proper communication among specialist care teams. Experts also emphasize that patients’ understanding should always be taken into consideration when documenting radiology reports.

Check out the infographic below

Radiology Reports

Read our blog on How To Document A Good Radiology Report

Medical Transcription Market Predicted To Reach USD 3.79 Billion By 2029

20-October-2022 MTS TEAM Medical Transcription

Medical Transcription Market

Medical transcription involves converting voice or verbal notes given by medical professionals, into predefined text or digital transcripts. Medical practices can now rely on various transcription options, ranging from automatic speech recognition (ASR) software to professional human transcribers. Professional medical transcription companies provide the services of experienced transcriptionists, who are equipped with the latest skills, tools, and technology to provide quick, accurate, and reliable transcripts of the recorded audio or video recordings.

According to a report from Data Bridge Market Research, the global medical transcription market is predicted to rocket up to USD 3.79 billion by 2029, which was USD 1.50 billion in 2021. The market is expected to undergo a CAGR of 12.30% during the forecast period 2022 to 2029. Along with the market insights such as market value, growth rate, market segments, geographical coverage, market players, and market scenario, this market report also includes in-depth expert analysis, patient epidemiology, pipeline analysis, pricing analysis, and regulatory framework.

Key factors that are driving the market growth are – the increase in the prevalence of several chronic illnesses, including melanoma, cardiovascular problems, diabetes and the increasing demand of medical records for those conditions. Other factors that are facilitating the market growth are – rapid urbanization, numerous benefits offered by electronic health records (EHR) and the introduction of high-end encryption technologies.

However, certain factors that are restraining the medical transcription market growth are – the rise of over-the-counter drugs, the launch of new goods, hospital administrators’ hesitation, fraud, and the unauthorized selling of patient data. Leading medical transcription companies have incorporated cutting-edge encryption technology, data security measures, and secure end-to-end information exchange processes despite the heightened risk of fraud or theft of medical data or information.

When it comes to the impact of COVID-19 on the medical transcription market, it is predicted that the epidemic would have a significant positive impact on the market. The recent development highlighted in the report is that in March 2020, ZyDoc announced the beginning of its free COVID-19 EHR services to all hospitals and healthcare organizations impacted by COVID-19.

The report is segmented on the basis of services type, technology, mode of procurement, and end user.

By services type, the market includes History and Physical Report, Discharge Summary, Operative Note or Report, Consultation Report, Pathology Report, Radiology Report, and others. By technology, the market is sub divided into Electronic Medical Records/Electronic Health Record (EMR/EHR), Picture Archiving and Communication System (PACS), Radiology Information System (RIS), Speech Recognition Technology (SRT), and Others. End users of this global market are – hospitals, clinics, clinical laboratories, academic medical centers, and others.

Geographically, the market is divided into – U.S., Canada and Mexico in North America, Germany, France, U.K., Netherlands, Switzerland, Belgium, Russia, Italy, Spain, Turkey, Rest of Europe in Europe, China, Japan, India, South Korea, Singapore, Malaysia, Australia, Thailand, Indonesia, Philippines, Rest of Asia-Pacific (APAC) in the Asia-Pacific (APAC), Saudi Arabia, U.A.E, South Africa, Egypt, Israel, Rest of Middle East and Africa (MEA) as a part of Middle East and Africa (MEA), Brazil, Argentina and Rest of South America as part of South America. Owing to the strong healthcare IT infrastructure and market players penetration in the anticipated period of 2022 to 2029, North America dominates the market. Asia-Pacific is expected to grow at the highest growth rate in the forecast period, due to the rising health awareness among the people and growing demand of advanced medical technology.

Key market players of this global market include Acusis LLC (U.S.), Transcend Services (Taiwan), Nuance Communications Inc. (U.S.), MModal LLC (U.S.), iMedX Inc. (U.S.), Global Medical Transcription LLC (U.S.), nThrive Inc. (U.S.), MTBC Inc. (U.S.), Medi-Script (U.S.), TransTech Medical Solutions LLC (U.S.), Mmodal (Canada), Outsource2 (India), TransPerfect (U.S.), VIVA Transcription Corp. (U.S.), Medscribe Inc. (U.S.), Pacific Solutions (U.S.), Same Day transcriptions Inc. (U.S.), DoctorDocs (U.S.), World Wide Dictation (U.S.), Athreon (U.S.).

While choosing a medical transcription outsourcing company, practices must consider several factors such as – accuracy, turnaround time, price, features, and more.

Telehealth Tips For Improving Your “Webside” Manner

17-October-2022 Julie Clements Medical Transcription

Telehealth

Telehealth originated several decades ago and over the years, became a viable alternative to make care accessible to people living in remote locations. The internet changed everything, allowing healthcare professionals to connect with patients using digital information and communication technologies such as computers, tablets and smartphones. During the COVID-19 pandemic, telehealth usage surged as an effective way to safely deliver healthcare. Medical transcription outsourcing ensures accurate documentation of these virtual consultations.

Whether the interactions are face-to-face or virtual, patient-centered communication is key to providing high-quality health care. As practices continue to rely on telehealth, physicians need to improve their ‘webside’ manner. Wiktionary defines webside manner as the way in which a healthcare professional interacts with patients remotely in telehealth or telemedicine. In other words, with telehealth usage, you need to maximize the patient experience by translating ‘bedside manner’ to ‘webside manner’. Let’s see how you can do this.

Ways to Improve Your Webside Manner and Enhance the Patient Experience

In telehealth, you’re not in the same room as the patient and new skills are needed to provide the necessary care. To succeed with telehealth, you need to know how to communicate and interact with patients in video visits and make them feel comfortable, and to feel that they will receive an efficient and satisfactory visit. Here are 7 tips to improve your webside manner:

Set up a good quality online communication platform: Invest in quality telehealth platform with interactive audio and video conferencing modules. This will allow you to diagnose the patient using visual clues, clearly hear what they are saying, and explain the treatment. By communicating effectively, your patients will feel reassured that their symptoms have been correctly identified, which is crucial to tailor treatment. Top technologies also allow patients to securely connect with their providers on any device and are fully featured to protect confidential patient data.
Pay attention to positioning and settings: Make sure your face is clearly visible to the patient by putting yourself in the center of the frame and ensuring uniform, glare-free lighting distribution. Make eye contact by focusing on the camera and not on the screen, as this will let the patient know that you are looking at them. Choose a neutral background and make sure that there is nothing that will take the patient’s attention away from you. Make an effort to understand the patient’s home environment and ask them to ensure that their settings and body position will allow for proper examination.
Etiquette matters: Courteous behavior can support a positive interaction. If you are meeting the patient for the first time, smile and introduce yourself. Tell the patient what to expect – this is especially important if it’s the patient’s first experience with telehealth. Before you end the call, make sure the patient understands the treatment plan and leave time for them to ask questions. Avoid distracting body language during the virtual visit. Your appearance matters too – dress professionally just as you would in the office setting.
Communicate clearly: Just as with in-person visits, building rapport and communicating properly with your patients is crucial in a telehealth visit. Avoid abbreviations and medical jargon as patients are less likely to ask for clarifications during online visits. Just as in an in-person visit, provide a plan for the patient, send notes to the patient and set up any referrals needed.
Listen and show empathy: For meaningful virtual interactions with patients, use skills and techniques that will convey empathy, build trust, and reduce anxiety. To make patients will be more comfortable, conduct the visit in a quiet, comfortable, private space. Take steps to mitigate interruptions and avoid multitasking during the visit. Use gestures to show the patient you are listening and don’t interrupt. Offer reassurance and encouragement.
Treat it like the in-person visit: Review the patient’s chart before the video visit, obtain the patient’s health history if necessary and as much clinical information as possible. Provide the same standard of care as in a face-to-face office visit. Explore whether peripherals can used for treating and diagnosing patients remotely. For instance, an electronic stethoscopeenables remote providers to listen to sounds similar to those at the point of care. Peripherals can be used to transmit high-definition audio, video, images, and other health data (such as vitals, blood glucose levels, etc.) from the patient to the off-site provider. Web-based or mobile apps, wearable devices that automatically record data such as heart rate, blood sugar, home monitoring devices, and devices that send notifications to patients can support telehealth interactions.
Practice, practice: Developing a webside manner requires practice. However, most providers conduct telemedicine visits without any previous training in this area, which leaves them as novices when it came to webside manner, says Neel Naik, MD, director of emergency medicine simulation education and an assistant professor of clinical emergency medicine at Weill Cornell Medicine, in New York City (www.ama-assn.org). The more you practice, the more you will be comfortable with telehealth

Outsource Medical Transcription

Focusing on the patient is an integral element of a successful telehealth visit. Use your computer to interact with the patient and not for any other purpose. If you make EHR notes, inform the patient that you need to capture their story correctly. You can rely on telehealth medical transcription services to document the visit and focus on your webside manner to deliver quality care.

Falling Behind On Patient Documentation? How To Complete It In Time

13-October-2022 Rajeev Rajagopal Medical Transcription

Patient Documentation

Medical records comprise different types of documentation on patient history, clinical findings, diagnostic test results, preoperative care, operation notes and discharge summaries. Completing patient documentation on time is a major challenge for busy healthcare providers. This is all the more challenging with the move from paper-based charting to electronic health records (EHRs). While a medical transcription service company can provide comprehensive support for medical record creation and maintenance, following best practices can help clinicians complete charting in time.

According to a study published in Annals of Internal Medicine in 2020, physicians in the U.S. spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. Researchers said that the duration of time that providers spend using EHRs to support the care delivery process is a concern, due to its potential effect on patient care and the high costs related to this time, especially for medical specialists. The study was based on approximately 100 million patient encounters with about 155,000 physicians from 417 health systems.

Though EHRs have made charting faster and more complete, they have taken away from patient time. Optimizing systems and processes is therefore essential to ensure proper documentation along with provision of quality care, and importantly, to prevent stress and burnout. Here are seven strategies to complete patient documentation in time, including recommendations from an article published by the American Academy of Family Physicians (AAFP):

Do EHR charting in the exam room: In addition to timeliness, the key benefit of completing documentation in the exam room is accuracy. As you discuss the patient’s health history or treatment plan and medication reconciliation, review aloud when you take or dictate notes. Dictating aloud will help engage the patient, improve understanding, and ensure accuracy. By documenting real-time in the EHR, patients can be given a printed-out summary of their visit as well as any prescriptions and referrals. For complex patients, Boston-based pediatrician Michael Lee MD said he documents key findings in the EHR, then revisits the patient record later in the day to document the visit more fully (www.medicaleconomics.com).

Get assistance for documentation: Involving your care team in the documentation process can save time. Have a nurse or medical assistant document patient outcomes, review medications, and verify or record allergies. You can sign the note after quickly assessing this information for accuracy.
Document only what is medically necessary: The AAFP notes that knowing the latest Evaluation and Management (E/M) guidelines is essential to ensure quick and accurate documentation. New guidelines and coding requirements were introduced in January 2021 for outpatient E/M CPT 99202-99215 office visits. History and/or physical examination are no longer elements for code selection. Physicians can opt to base their documentation on medical decision making (MDM) OR the total time spent on the day of the encounter.

Use the EHR’s time-saving features: EHR systems come with many time-saving features. In a Vision Expo West survey, eye-care professionals listed the favorite time-saving features of multiple EHR systems as: flexibility and remote access to files, quick access to patient records, including past office visits; free text type feature to add notes to patient encounters; pre-built exam templates customizable boxes, auto-fill options and drop downs; cloud-based practice management software that allow quickly pulling up the physician’s schedule to make sure patient visits run on time, etc. Templates are useful for routine visits with standard clinical queries but for complex or changing situations, manual typing or mobile dictation may be the fastest, notes MobiusMD. However, experts recommend using Templates and the copy and paste functions judiciously as they can bring in information that is no longer relevant to the patient’s current condition.
Don’t strive for perfection: If you are a die-hard box-checker or perfectionist, completing EHR tasks will take forever. Document only what’s needed based on the EHR documentation guidelines and check only those boxes that are essential.
Don’t go into lengthy explanations: The AAFP explains: “The clinical note serves as neither biography nor ethnography. Be brief and focused. In the plan section of the note, be clear and concise enough that the next person looking at your note will be able to understand your clinical reasoning and follow the plan”.
Track your performance: Time yourself to see how much time it takes for you to complete a clinical note. Then set your goals and work to achieve them.

Delays in completing EHR documentation can hinder clinicians’ ability to provide quality coordinated care. These strategies can go a long way when it comes to getting your EHR notes done quickly. However, there’s one downside when it comes to documenting in the exam room – it can take attention away from the patient. Outsourcing medical transcription can ensure timely, accurate, and complete notes as you focus on your patients. Family practice medical transcription services can help physicians manage heavy workloads and ensure that all clinicians engaged in the patient’s care have access to accurate, up-to-date, and complete information.

View our infographic on How To Finish Patient Visit Documentation In Time [INFOGRAPHIC]

Four Key Reasons Why Medical Transcription Is Important Today

10-October-2022 MTS TEAM Medical Transcription

Medical Transcription

Healthcare professionals have a lot to juggle between providing patient care, offering counselling, and completing routine exams. They must also maintain correct patient records, which is difficult to accomplish when you have to write down everything. To make their jobs a little easier, medical professionals like doctors, nurses, and nurse practitioners record their notes using voice recorders, which are then afterwards transcribed using medical transcription. While doctors are free to concentrate on giving the patient the finest care possible, reputable medical transcription services enable them to create accurate medical records.

Medical Transcription Relevant Even in the EHR Age

Doctors create audio files with all the information about your physical condition, past and present illnesses, prescription medications, lab and pathology reports, tests, and diagnoses. An MT listens to the audio recording, reports the findings, and then checks the document for errors and inconsistencies. This document is now an essential part of the patient’s medical history that doctors, nurses, and other healthcare professionals can access as and when necessary.

Medical transcriptionists will always hold a strong position in the healthcare industry, but it’s critical that they stay current with changes in the field. Over the years, a medical transcriptionist’s job description has expanded to include more than just transcribe. Now, the medical transcriptionist must have the ability to modify voice recognition draft reports as well as proofread them. Everyone has the perception that medical transcribing is a trend that is quickly disappearing because of the tremendous progress in speech recognition software, but this is untrue. The field of medical transcribing is one that will continue to exist as long as transcriptionists stay up to date on the latest developments. Moreover, now medical transcription companies provide EHR-integrated transcription which is a great support for physicians.

Learn more: 5 Key Roles Of Medical Transcription In Healthcare

4 Reasons Why Medical Transcription Should Still Be Used

Helps in Medical Condition Evaluation: In order to create a patient’s medical history, which serves as a resource for doctors and the foundation for subsequent patient visits, medical transcribing is a crucial step. It helps the doctors examine the patient’s current physical condition, create a suitable treatment plan, and implement necessary follow-up actions. Accuracy is a crucial element as well. A small mistake might cause major problems. A quickly written prescription could result in a carelessly added or deleted zero, which could substantially alter the dosage and have devastating effects on the patient.
Healthcare Is Becoming Increasingly Collaborative: It is extremely unlikely that only one doctor or healthcare worker will focus on your case even if you go to a small clinic, therefore complicated patient data is crucial to ensure proper care. Sharing information is a crucial component of the heart of a healthcare facility, especially when a case requires the knowledge of several doctors in diverse sectors or specialties. Medical transcriptionists can help with that. Their records include crucial medical and treatment information that can be shared among multiple practitioners to ensure that messages are succinct and understandable and that everyone is on the same page. Regardless of the size of the team, these crucial transcriptions help to improve the flow of information between doctors, ensuring that the right diagnosis and treatment choices are implemented.
Ensure Uniformity For Insurance Purposes: Medical records are very significant. Medical transcriptionists are given a number of responsibilities, from ensuring that consistent, proper care is supplied around a full medical team to safeguarding healthcare practitioners from court cases and lawsuits. Trusting them to produce consistent, accurate, and HIPAA-compliant documentation of recorded information is crucial for your healthcare facility’s operations and patient care, as well as for billing insurance companies for the price of the service provided. Medical records according to which health insurance carriers are billed must be accurate, if not, your facility won’t get paid. That’s why accurate medical transcription is important.
Communication is Kept Open across the Facility: Support staff and nursing are responsible for ensuring that patients are cared for and receive the appropriate therapies while specialists and doctors are not working with them. These visible medical records will ensure that all staff members at the treatment center have the same information to maintain the patient’s health and avoid issues or setbacks. Medical transcriptionists are highly specialized and have extensive training in addition to their experience. They can help you expedite the process, help more patients, and have stronger, more accurate records than ever before, all for a lower price than any of the other solutions available.

All the reasons listed above point out how crucial medical transcriptionists are to keeping an accurate record of a healthcare facility. So, if you are a physician or you own a healthcare set up, you should work with a medical transcription company that has a track record in the industry to ensure optimal accuracy and excellent outcome.

Strategies To Improve The Patient Referral Process

06-October-2022 Julie Clements Medical Transcription Outsourcing

Patient Referral

Medical practices need a strong referral network to ensure that patients receive optimal care from the right providers when they need it. While family practice medical transcription service companies can provide timely and accurate patient records, primary care physicians (PCPs) need to share these records with other providers and specialists to ensure that patients receive optimal care at the appropriate level. In addition to supporting efficient management of a patient’s health, a proper referral system is necessary for practices and hospitals to attract new patients consistently, grow revenue, and succeed. Importantly, to cover specialist treatment, most insurance companies require referrals to ensure the treatment is proper and medically necessary.

Trends in Physician Referrals

Here are some physician referral statistics from Referral MD:

In the United States, more than a third of patients are referred to a specialist annually, and specialist visits comprise more than 50 percent of outpatient visits.
Up to 63% of referring physicians are frustrated with the current referral process due to a lack of timeliness of the information and inadequate referral letter content. Even if data transfer takes place to or from the specialist, it is often insufficient for medical decision making.
25 to 50% of referring physicians do not know whether their patients have seen the specialist to whom they were referred.

According to HealthViewX:

Almost 20 million referrals made in the US every year are clinically inappropriate.
Only 54% of referrals result in a completed appointment.
More than two-thirds (68%) of specialists receive no information from PCPs prior to referral visits (Journal of General Internal Medicine).
40% of PCPs do not receive consult reports back from specialists following referrals (Archives of Internal Medicine).

Clearly, there’s room for improvement in the patient referral process. The efficiency and timeliness of the referral process can be improved with focused efforts and appropriate resources. A proper referral process can improve care, enhance practice performance, boost patient satisfaction, and promote referral compliance.

Let’s look at the challenges of managing patient referrals and expert strategies to improve the process.

Medical Referrals – Challenges and Solutions

Proper connection among different caregivers: Lack of coordination different caregivers is a major problem affecting the referral system. For referrals to succeed, there must be proper communication and coordination among the providers involved in the patient’s care, such as primary care physicians, specialists, and other health providers in hospitals, medical units in a hospital, specialty clinics, and different clinical settings such as ambulatory care, inpatient care, and emergency care.HealthViewX notes that the leadership team should be aware of which physicians are making referrals and develop a well-connected team structure. Proper communication between the leadership team and physicians regarding referrals to specialists can help prevent overutilization and ensure that all necessary documentation is transferred during every referral.

Sharing vital information or documentation – If the referring physician fails to send important patient information such as vital symptoms and results of initial tests along with the referral order, it can affect the efficiency of the referral process. Specialists may end up making a fresh diagnosis without knowledge about the patient’s care history while primary providers would be unaware about the type of care the patient received. Sharing vital patient information with the receiving physician and keeping the patient informed is crucial for patients to receive appropriate treatment from specialists and avoid health complications. The type of information that needs to be shared would depend on the goal of the referral.Electronic medical records (EMRs) along with medical transcription outsourcing and electronic referral forms can improve communication and information transfer between PCPs and specialists sharing the EMR. Experts recommend using the SBAR (Situation-Background-Assessment-Recommendation) method:
- Situation: Describe the exact circumstances of the situation. Focus on the seriousness of the situation and exclude non-essential information.
- Background: Presents essential information related only to the current situation.
- Assessment: Provide a precise statement by a qualified staff member explaining the situation and background information.
- Recommendation: The qualified staff member makes a statement on the reason for the referral and a recommendation for resolving the issue based on the situation, background, and assessment. Time frames may be specified, if necessary.
Follow-up: If primary care practitioners fail to follow-up after they’ve referred a patient to a specialist, it can put patients at risk. Tracking and receiving status updates on every patient referral is crucial to ensure that patients received timely and appropriate care.
The best way to track referrals is with a referral management system. For instance, ReferralMD’s system sends notifications informing the referring physician when the receiving provider schedules an appointment with their patient and the time the provider actually sees the patient. Both the referring and receiving practices can notify each other in real-time about a patient’s appointment status. By tracking the progress of referrals throughout their life-cycle promotes transparency and accountability, prevents risk of miscommunication, and fosters better care coordination.

Both referring providers and healthcare organizations and specialists receiving patient referrals should review their system and take steps to improve it where necessary. This will enable patients to get the best possible care. Studies have found that referral marketing can enhance medical practice growth by attracting new patients, increasing brand recognition and boosting return on investment (ROI). Adopting technology to share information and keep communication channels open will eliminate paperwork and streamline the referral process. Medical transcription outsourcing is the best way to ensure medical records that demonstrate continuity of care and response to treatment.

How To Document A Good Radiology Report

03-October-2022 Rajeev Rajagopal Radiology Transcription

Radiology Report

Accurate radiology reports clearly communicate chronic incidental findings, the diagnosis or differential diagnosis, the clinical implications of radiologic findings, and any chronic findings that need additional workup or surgical intervention, along with recommendations for management. Error-free radiology reports contribute to patient care. With increasing workload, backlogs and malpractice risks posed by reporting errors, radiology transcription services are a viable option to generate accurate radiology reports. Outsourcing medical transcription will ensure seamless, accurate and timely capture of dictated radiology reports, including entry of patient information in the radiology information system (RIS). Transcriptionists also review and edit transcribed reports generated by speech recognition apps. However, radiologists need to know what constitutes a good radiology report. In this blog, we put together expert views on this matter.

The radiology report is an important document that helps guide patient care and becomes part of the patient’s permanent clinical record. These reports are seen not only by the ordering physician and but also by subspecialty providers involved in the patient’s care, other radiologists, and patients and their families. However, studies indicate that radiology reports are prone to different types of errors:

Typographical errors
Serious omissions such as missing tumors and lesions
Misinterpretations – faulty reasoning, bias, and errors in interpretation can lead to an incorrect diagnosis
Inconsistencies in report formatting and language

Creating a good radiology report that clearly communicates the findings of imaging tests is a complex skill that requires continuing effort and attention.

What is a Good Radiology Report?

A concise, well-crafted and well-organized digital radiology report would include the following information:

Patient demographics – patient name, number, date of exam, type of exam
Indication for study (such as a symptom or sign) or clinical history
Technique used – study type and modality
Description of pertinent findings – both positive and negative findings
Radiographic diagnosis – a likely diagnosis or differential diagnosis that linked to clinical indication given for the exam
Next steps
Timed and dated electronic signature

An article published in RadioGraphics lists the 5 basic principles of clear, concise radiology reporting that can benefit both trainees and practicing radiologists:

Provide the favored diagnosis or differential diagnosis along with the key finding to support it.
State the findings clearly in understandable language. Avoid technical language that only radiologists know.
Avoid clinically insignificant information and provide only information that is relevant to the ordering physician.
Provide relevant detailed recommendations that can help the provider reach a specific diagnosis or will guide management of the condition.
Continually work on improving the report based on provider feedback and following up biopsy results, hospital courses and procedural and operative notes.

Other tips from www.brighamandwomens.org:

Highlight short, informative, and factual observations in the finding sections; avoid improper interpretation, overusing terms of perception, and redundancy
Write complete sentences and don’t use abbreviations whenever possible
Ideally, findings should be distinct and separate from the impressions.
Ensure that observations are kept brief and succinct

Experts also emphasize that patients’ understanding should always be taken into consideration when documenting radiology reports.

Unstructured Reporting vs Structured Reporting

There are two types of radiology report formats – unstructured and structured – and each comes with its pros and cons. Unstructured reports or the standard free-text approach and are created by radiology transcription companies from the radiologist’s dictation. The narrated version allows the radiologist to describe relevant radiologic findings and offer several benefits such as conciseness and customization. However, it has certain drawbacks. As it focuses on including only specific information, important radiologic findings may be understated. Further, inconsistency in the language and format can cause miscommunication, making these reports challenging for both patients and other users.

Several studies show that, due to all these reasons, most referring physicians prefer structured radiology reports to free text (www.ajronline.org). In this type of report, structured templates allow for reporting the findings with brief observations, while maintaining the meaning of the findings with actionable information. Proponents say it improves readability, reduces risk of omission of relevant information, and presents the critical findings effectively. Medical transcription companies with expertise in radiology documentation can ensure as much relevant information as possible, easing the work overload of the radiologist.

Medical imaging reports should be optimized to provide pertinent information to physicians reading them as well as patients. The benefits of well-crafted, optimized radiology reports also include proper communication among specialist care teams, and improved algorithm training, according to Quantib, a market leader in artificial intelligence in healthcare & radiology.

View our infographic on 9 Best Tips To Document Radiology Reports [INFOGRAPHIC]

How A Fruitful Patient-Physician Relationship Can Optimize Care

26-September-2022 Julie Clements Medical Transcription Outsourcing

Fruitful Patient-Physician

The patient–physician relationship is a key component in effective health service delivery, especially in this digital age. A trusting, informative relationship between the patient and the physician can promote patient compliance with the treatment. However, as the current healthcare environment is increasingly complex and puts pressure on providers to increase clinical productivity, physicians have less time for patients. While outsourcing medical transcription can help physicians manage the EHR documentation tasks, they need to focus attention on building a fruitful relationship with their patients in order to optimize care.

Successful Communication Improves Patient Outcomes

A study published in the Journal of Patient Care in 2021 found that the patient–physician relationship and shared decision-making has a positive impact on patient compliance with the treatment. When physicians communicate with patients in an effective and empathetic manner, they may be able to obtain more complete information, which can help them provide a more accurate diagnosis and also optimize care.

Effective physician-patient interactions offer many benefits:

Supports early and accurate diagnosis: Effective communication can help providers obtain proper history from a patient, which is crucial to establish an accurate diagnosis. According to the National Center for Biotechnology Information, engaging patients who take an active role are more likely to provide the type of information providers need to make most diagnoses. Miscommunication can also lead to a medical condition going unnoticed.
Helps in developing the treatment plan: An early and accurate diagnosis is necessary to develop the most appropriate and effective treatment plan. Clear, honest communication between patient and provider paves the way for treatment decisions.
Promotes patient compliance: One of the key goals of communicating with the patient should be to provide the advice they need to set and achieve sustainable health goals. An effective patient-physician relationship is necessary to educate patients and make them understand the treatment plan, which will promote patient compliance and improve care.
Builds patient trust and satisfaction: Good patient-provider relationships build patient trust. Studies show that patient trust is important for higher patient satisfaction scores (patientengagementhit.com). Strong communication skills are essential for providers to build patient trust.

Strategies for Building a Fruitful Patient-Physician Relationship

To optimize care, physicians need to focus attention not only on establishing an initial culture of trust with their patients and also to continue to foster that trust throughout the customer life cycle, according to Jason Burum, vice president of patient engagement and clinical effectiveness at Wolters Kluwer Health, (www.physiciansweekly.com). The focus should be on conducting patient-centered interviews.

Here are seven ways to improve patient–physician communication:

Build rapport: Ensure a comfortable seating arrangement and maintain eye contact. Use good non-verbal and verbal skills and speak at a proper speed show empathy and warmth, and maintain an engaging tone of voice that reflects genuine interest in the patient. This will help your patient feel comfortable with you.
Ask open-ended questions: With open-ended questions, patients will reveal more details. Using proper Interviewing techniques will help busy physicians effectively obtain a complete medical history and other relevant information. ACOG says that physicians can consider hiring nonphysician health care providers, such as advanced practice nurses or physician assistants, with patient-centered interviewing skills to assist with established patients.
Listen: Listen actively and pick up leads from what the patient says or does. To help patients prepare for the appointment, ACOG recommends asking them to write down their questions in advance. This can promote conversation on topics important to the patient. Always ask for clarification where necessary.
Pay attention to non-verbal cues: There are two aspects in nonverbal communication during the medical consultation – the non-verbal behavior of the patient and the non-verbal behavior of the physician. Physicians need to focus on understanding patients’ non-verbal cues to pick up patients’ non-verbal cues in their conversation, facial expressions, and body posture. Likewise, they need to know how their own non-verbal behavior such as eye contact, body position and posture, movement, facial expression, and use of voice can impact the success of the consultation.
Avoid use of jargon: Use simple language when talking to patients. Medical jargon confuses patients and can lead to alienation and misinterpretation and misunderstanding.
Technology: Effective use of online technologies can improve physician-patient communication. Smartphones, apps, chat boxes, email, electronic health records, patient portals and telemedicine systems can be used to share information, allowing providers and patients to interact at any time, from anywhere. By creating an open dialogue between patients and physicians, technology can build trust and strengthen their relationship. Health information technology systems should comply with the Health Insurance Portability and Accountability Act (HIPAA) rules as well as state privacy laws.
Patient education: Patient education is critical to for an effective patient-physician relationship. 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”. Physicians should ensure that patients have a better understanding regarding their diagnoses and treatment options as well as general wellness and preventative care. Health literacy can empower patients and help them make rational health choices.

A fruitful patient-physician relationship is clearly the key to optimizing care. It could also reduce physician burnout, according to a survey conducted by Merritt Hawkins on behalf of the Physicians Foundation. Up to 79 percent of physicians said patient relationships are their greatest source of job satisfaction. The survey reported that inefficiency of EHR use is the leading source of clinician burnout. It can also affect physician patient communication. Outsourced medical transcription services are an ideal way to address this. With a competent service provider handling their EHR documentation tasks, physicians can focus on what really matters – building a positive relationship with patients to optimize care.

Guidelines For Chiropractic Documentation

19-September-2022 MTS TEAM Medical Transcription

Chiropractic Documentation

A chiropractor can have a large number of health records to deal with on a weekly basis, and that means a lot of notes that must be transcribed. This process can take a great deal of time, which could mean less time spent seeing patients or a backlog of paperwork. This problem can be resolved by working with a reputable medical transcription service that can generate accurate chiropractic medical records.

It is crucial to properly document each visit since it facilitates communication among healthcare professionals. It examines the care the patient received from the time of admission until discharge, covering issues like diagnoses, treatments, and the resources employed. Medical practitioners’ ability to communicate with one another is facilitated by accurate, detailed, and extensive documentation. Chiropractic doctors, like all other healthcare providers, are required to keep thorough records of all their patient interactions. This can safeguard both their patients and themselves.

Tips to Generate Accurate Chiropractic Records:

The following apply whether an x-ray or physical examination reveal the subluxation.

The patient’s history that contains:
- The symptoms that led to seeking medical attention and also their primary complaint that brought them to the treatment.
- Details regarding the patient’s and his/her family’s overall health, any previous illnesses or injuries that could affect their treatment, any drugs they are now taking, and whether they have ever received chiropractic care.
Details about current illness:
- the mechanism of trauma
- the quality and nature of the symptoms/problem
- Onset, duration, intensity, frequency, location, and the radiation of symptoms are all included
- Aggravating or relieving factors
- Prior interventions, treatments, medications, secondary complaint
- The degree of subluxation must be directly correlated with these symptoms. The symptoms should be stated as pain (algia), inflammation (itis), or as signals like swelling, spasticity, etc. They should pertain to the spine (spondyle or vertebral), muscle (myo), bone [sic] (osseo or osteo), rib (costo or costal), or joint (arthro).

It is insufficient to just declare that there is “pain.” It is necessary to define the pain’s location and verify whether the listed vertebra in question is able to cause it there.

Assessment of the musculoskeletal and nervous systems via physical examination or x-rays:
Identify how it was established that the patient’s pain when they first arrived was caused by a subluxation. Two of the four P.A.R.T. criteria-one of which must be asymmetry/ misalignment or range-of-motion abnormality-must be met in order to identify a subluxation based only on a physical examination.
- evaluation of the location, nature, and degree of pain or soreness
- a sectional or segmental level asymmetry or misalignment
- abnormalities in range of motion
- alterations in the properties of adjacent or connected soft tissues.
Diagnosis:
- The primary diagnosis must be subluxation, including level of subluxation, either as expressed or indicated by a phrase that describes subluxation. Such words may refer to the state of the affected spinal joint or the direction that a certain bone is moving in.
- To support the condition that led to the first diagnosis, secondary diagnostic is necessary.
- Each level of the spine that is modified and invoiced for requires notes to validate these diagnosis codes.
Treatment plan:The following elements must be included in the treatment plan:
- The recommended level of care (length and frequency of visits)
- Specific treatment objectives
- Evaluation of treatment effectiveness using objective metrics

Some Documentation Tips

Give thorough and readable documentation
Clearly state the need for medical care
Use standardized acronyms
Include a treatment plan
Provide specific date of service elements
Specify which services are required
Each level billed must be supported with documentation
Be cautious when using software-generated documentation, as some may have similar items for several patients or service dates
Be cautious when using check-off forms because they might be challenging to read, lacking in findings, overly general, and lacking adequate space to list all the necessary information
Be cautious when including non-encounter specific repetitive items that lack the components required by policy and were rejected after evaluation

Like any other doctor, chiropractors are subject to audits and malpractice lawsuits. It’s crucial that you have quick access to accurate medical records in case either of these scenarios occurs. It also helps avoid the risk of being out of HIPAA compliance if you attempt to type out your own reports or have a member of your team transcribe them. To create reliable medical records for chiropractors, it is therefore best to get in touch with chiropractic transcription services or medical transcription services. It’s critical to have your claims and documentation reviewed to make sure they withstand scrutiny with an audit or investigation, and are in good health for the business as well as for improved patient care.