How to Ensure Your Documentation Meets the MEAT Criteria

02-March-2023 MTS TEAM Medical Transcription

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

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

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

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

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What is MEAT?

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

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

MEAT Criteria to Establish Presence of a Diagnosis

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

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

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

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

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

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

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

Medical Transcription Outsourcing supports Accurate and Comprehensive Documentation

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

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

Most chronic conditions are assigned to an HCC.

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

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Medical Documentation of Burn Injuries

27-February-2023 Julie Clements Medical Transcription

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

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

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

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

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

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

Burn Documentation Features

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

Advanced burn documentation should include:

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

Proper TBSA Estimation

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

Lund Browder Chart

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

Rule of Nines

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

Rule of Palms

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

Choosing a Perfect Documentation System

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

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

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

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

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

Dos and Don’ts of Maintaining Good Clinical Records

23-February-2023 Rajeev Rajagopal Medical Transcription Outsourcing

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

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

Clinical Documentation: Dos and Don’ts

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

Physician-Patient Email Communication – Key Considerations

20-February-2023 MTS TEAM Medical Transcription Outsourcing

Physician-Patient Email Communication - Key Considerations

All physicians know that patient outcomes depend on successful communication. Open communication can help providers obtain more complete information from patients, improve the prospects of a more accurate diagnosis, and promote proper counseling, thus potentially improving patient adherence to treatment plans and health outcomes. With efficient EHR documentation support from medical transcription outsourcing companies, physicians are leveraging information technology to improve the quality of care. Electronic communication with established patients via email or text messaging is a useful strategy in many situations and can enhance the patient experience.

An increasing number of physicians are using electronic health records and web messaging to communicate with their patients. Email allows physicians to reach patients quickly and keep them informed about upcoming appointments or follow-ups, send medication prescriptions and advice, and more. This is especially useful in emergencies like the COVID-19 pandemic. One study found that 63% of physicians used email for their telehealth activities during the pandemic. However, providers have to take certain factors, especially security, into account when using email.

Important Considerations when using Email to Communicate with Patients

According to the American Medical Association, email correspondence should be used to supplement personal encounters, and not to establish a patient-physician relationship. Here are the things physicians have to keep in mind when using email to communicate with patients:

Privacy and confidentiality: There are security concerns when using non-secure email accounts to communicate sensitive information, including increased risk of HIPAA violations. Best practice is to use applications that can encrypt the email message. Today, healthcare providers have a wide choice of cloud-based and on-premises security tool combinations that they can use to protect data, and safeguard email and other electronic communication. While the HIPAA does not prohibit the use of unencrypted e-mail for treatment-related communication between health care providers and patients, practices should have protected server supported by a firewall. Providers should also be aware about what types of information cannot be send via email.
Notify patients about the risks: When using unencrypted email, physicians should get the patient’s informed consent for the same and ensure that the patient has acknowledged the risks. Use simple language in emails and encourage questions. Patients should be given the opportunity to accept or decline sending privileged information electronically. Here are 3 things that patients should be informed about, according to www.doctorsofbc.ca on:
- how emailing or faxing personal health information poses risk of accidental disclosure or interception by other parties
- precautions taken by the practice to reduce the risk of email breach
- What other more secure delivery options are available to send/share sensitive personal health information (such as sending hard copies by courier)

Patients should be informed about who will see and process their messages. When communicating via email, instruct patients to include their name and patient ID number. To remind patients about the sensitivity of the contents of the email, include a HIPAA email disclaimer. This could make them reconsider what they send in the absence of security measures.

Share educational material: Email is a great way to share health-related material with patients. Many people browse the web to get health information, but the content that comes up is not always accurate and reliable. They can trust educational material sent by their own physician.

Types of content to share with patients include: healthcare news, expert-reviewed medical articles and studies, seasonal tips, benefits and concerns about procedures/medications, strategies to prevent common health problems, and patient stories. Besides educational material, email can be used to send patient statement reminders and appointment reminders.

Develop written office policies and procedures on using email to communicate with patients: Providers should follow the American Medical Association Guidelines for Patient-Physician Electronic Mail and Text Messaging (www.ama-assn.org). Key recommendations include:
- Use email communication only with the practice’s established patients.
- Communicate only what’s permitted such as scheduling appointments, requesting non-narcotic prescription refills, reporting normal test results, providing advice for non-urgent medical concerns.
- Don’t use email to discuss highly-sensitive issues such as HIV test results, STD test results, mental health information, information or questions about sexual activity and abnormal test results.
- If using paper records or a stand-alone EMR system, print and initial patients’ email messages and your responses to the medical chart.
- Establish responsibility for checking email and responding to different types of messages.
- Set a turnaround time for email messages so patients will know when to expect the physician’s answer to their inquiries/questions.
- Notify patients about the limitations of responding to inquiries they send by email regarding medical evaluations and diagnoses, dispense medical advice, or prescribe new medications.
- Establish an automatic reply to patients to acknowledge receipt of their messages
- If the physician is unavailable to check email or the office is closed, create an automatic reply to inform patients about this, including how long you will be unavailable, and whom to contact (and how) in your absence.
- Instruct patients to confirm that they have received a response to their email.
Save copies of patients’ email messages: If patients’ messages contain valuable information about their health, store this in their medical record after informing them that you are doing so. Removing sensitive information from your inbox is also important for HIPAA, especially if the email is unencrypted. The saved information can be referred back to during future visits if needed.

Using email correctly can help patients and physicians communicate instantly. Email communication is also easy and reduce unnecessary or missed visits, amount of voicemails received, and hours spent on the phone. However, both patients and physicians should be well aware of the pros and cons involved. Email should never be used to report abnormal test results or give out medical advice. Abnormal results of tests should be discussed in an in-person consultation or by telephone, so that the patient understands the information and follow-up advice. Likewise, medical advice should be dispensed only after proper assessment.

As physicians focus on providing quality care and communicating with patients using the right strategies, they can rely on a HIPAA-compliant medical transcription service provider to manage electronic health records (EHRs).

Advantages of Using EHR Data for Clinical Research

16-February-2023 Julie Clements EHR Transcription

Advantages of Using EHR Data for Clinical Research Data collection and management in clinical research involves gathering variables pertinent to the research hypotheses and using it to generate high-quality, reliable, and statistically sound results from clinical trials. Clinical researchers collect both primary data from surveys and interviews and secondary data from paper records and electronic health records (EHRs). Medical transcription outsourcing plays a key role in ensuring high-quality, accurate EHR data for statistical analysis. With the widespread adoption of electronic health records (EHRs), the data they contain has emerged as a valuable resource for clinical researchers.

What Data do Electronic Health Records Contain?

Electronic medical records (EMRs) contain medical and clinical data that is routinely collected during medical care in a specific practice, clinic or other medical setting. EMRs are digital versions of paper charts. EHRs contain all of the information in EMRs but go beyond one provider or setting. EHRs contain information from all the clinicians involved in the patient’s care and focus on the total health of the patient. Electronic records are sharable among authorized providers, health organizations and clinics.

An electronic health record (EHR) contains the following patient health information:

Administrative and billing data
Patient demographics
Progress notes
Vital signs
Medical histories
Diagnoses
Medications
Immunization dates
Allergies
Radiology images
Lab and test results

Most organizations rely on medical transcription services to ensure accurate and timely EHR documentation. With the comprehensive medical information they contain, EHRs are an important tool for clinical researchers.

Benefits of Leveraging EHR Data for Clinical Research

Collecting clinical data manually via surveys is an arduous task. Moreover, the data collected would be limited to a specific population. Likewise, as claims data comes with a time lag, it may be an imperfect reflection of the actual status of a patient. Compared to these options, leveraging EHR data offers many advantages for clinical research:

Accurate: EHR data is considered the best option for health research as it provide precise, real-time information such as demographics, bedside monitor trends, laboratory test results, procedures, medications, caregiver notes, imaging reports, and mortality – for a large population of patients.
Better identifies the patient’s medical problems: EHR data enables better identification of the medical condition as it provides access to data elements such as lab results and vital signs that allow a diagnosis to be ascribed, even if that diagnosis was never made. The EHR also has a problem list which allows the provider to keep track of all the medical problems affecting the patient. With the EMR problem list, researchers can identify conditions which claims data may not be able to identify.
Rich dataset: EHR datasets offer rich data for clinical research that includes lab results, vital signs, patient surveys, habits (smoking, etc), problem list, etc. Such information is extremely important for understanding the full health status of a patient, but not available in other data sources such as claims.
Scope of patients: Another benefit of EHR data is that it covers the clinical information on all the patients in a provider’s group, including uninsured patients. That’s why clinical analysis done to improve the health status of a provider group’s full patient population needs to rely on EMR data as its source, rather than claims data (www.optum.com).
Timely data: Providers enter data into the EMR during the patient encounter or soon after it (with the help of a medical transcription service). This ensures real-time generation of the patient’s medical data. So, evaluating data from the EMR can provide fast insights.
Helps support equity research: In a JAMAop-ed, author Elham Hatef, MD, MPH from the Johns Hopkins School of Medicine and Bloomberg School of Public Health, noted that the use of real-time EHR data can help support health equity research (www. com, 2021). To highlight this, Hatef referenced a study that leveraged individual-level EHR data to prove its hypothesis that the neighborhood food environment was associated with increased type 2 diabetes risk among veterans in multiple community types.

Challenges of Using EHR Data for Clinical Research

As EHR software is accessed directly by physicians to record the details of their encounters with patients, it is a rich source of data for clinical research. However, reports indicate that using this data comes with certain challenges:

Lack of structured data collection, standardization and aggregation across sites was a major problem, according to a study that evaluated responses from a survey of research teams conducting clinical trial projects.
Using EHR system and building a reusable EHR data collection infrastructure takes time and effort.
EHR data would be a reliable source of data for research only if all of the physicians involved in the patient’s care use EHRs. Any services provided by a physician not using these electronic records will not be reflected in the data.
If the EMR system is not connected to the pharmacy, it may not confirm whether a patient filled or refilled his/her prescription.
EHR interoperability is essential to support research.

Partnering with an experienced medical transcription service organization can help providers ensure that EHR systems have the high-quality data necessary for use in clinical trials. Studies are exploring how to integrate EHRs from heterogeneous resources and generate integrated data in different data formats or semantics to support various clinical research applications (www.sciencedirect.com). EHR optimization for health data interoperability is also important to support clinical research. Integrating research with clinical care can lead to higher rates of clinical trial participation within a health system, improved health outcomes, lower cost of care, and more satisfied patients, according to experts. The COVID-19 pandemic also demonstrated the importance of such integration to provide better health options for all patients.

Modules of a Good Electronic Health Record

09-February-2023 Rajeev Rajagopal EHR Transcription

Electronic Health Record

Digital technologies are transforming the way the world operates. Electronic health records (EHRs) have all but replaced paper records in modern healthcare organizations, and revolutionized the way patient data is collected, stored, managed and exchanged. Most providers outsource medical transcription to input the medical and treatment histories of patients into the electronic chart. EHRs are much more than a storehouse of clinical data. A good electronic health record would have components that drive better value-based care, interoperability, and much more.

How EHRs benefit Patients and Healthcare Providers

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

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

Components of an EHR System

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

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

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

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

How Can You Improve Clinical Documentation?

06-February-2023 MTS TEAM Medical Transcription

Clinical Documentation

Clinical documentation comprises all the information relating to each patient’s encounters with a healthcare facility. This information is entered in the medical record by a member of the patient’s healthcare team – a physician, nurse, therapist, dentist or other healthcare professional. Chronologically documenting this information in the medical record is essential for the provision of continuous, high quality care. With the rising incidence of patients with chronic conditions and complexities of EHR data entry, many practitioners consider medical transcription outsourcing a reliable strategy to create proper medical records.

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

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

Why CDI is Vital for Patient Care

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

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

Purposes of Clinical Documentation

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

Good clinical documentation is important for many reasons:

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

Strategies to Improve EHR Clinical Documentation

Strategies to Improve EHR Clinical Documentation and Save Physicians’ Time

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

Other Recommendations

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

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

Benefits of Clinical Documentation Improvement

CDI is beneficial for many reasons:

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

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

What Are the Common Errors in Medical Documentation?

30-January-2023 Rajeev Rajagopal Medical Transcription

Medical Documentation

Medical documentation plays a key role in ensuring continuity of care, accurate billing, and regulatory compliance. Even small mistakes in records can affect clinical decisions, delay treatment, and create legal and financial issues for healthcare providers. These mistakes can occur due to time constraints, inconsistent note-taking, unclear terminology, or incomplete patient information.

Understanding the common errors in medical documentation is the first step toward preventing them and maintaining clear, reliable patient records to support quality care, compliance, and accurate billing. As healthcare systems face increasing documentation demands, many providers turn to medical transcription outsourcing to improve clinical documentation accuracy.

Medical Record Documentation Errors

Five Common Medical Documentation Errors

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

Confusing Statements from a Physician leading to Misinterpreted Dictation or Transcription Errors: If patient’s medications, procedures, and activities and ongoing developments in treatment are not transcribed correctly, it can significantly impact clinical documentation accuracy. These impact all caregivers of the patient, leading to miscommunication, care delays, and downstream coding and billing issues.
Not Documenting Prior Treatment Events: Leaving out even small details of the treatment given to the patient across nursing shifts can have disastrous consequences. All incidents that occurred and treatment provided should be documented so that there is no room for doubt about the patient’s condition. The Nurse Service Organization (NS) recommends that nurses leverage hospital standard flow sheets in the patient’s EHR to document details of the treatment given to the patient.
Not Placing an Operative Note on the Chart Immediately after an Operation is Performed: The operative note should be dictated and signed within 24 hours of operation/procedure. This document records the operation that the patient had, what was found during the surgery, and the surgeon’s post-operative instructions. Having this information in the chart is crucial for continuity of care when patient is moved into the recovery room or discharged.
Medication Errors and Omissions: Medication documentation errors can occur during prescribing, transcribing, dispensing and during administration. It is critical to record every medication given to the patient over the entire course of treatment-including the dose, route, and time of each administration. Studies found that many mistakes were due to dose omissions, wrong dosage or over dosage, and extra dosages. Errors were also caused by improper documentation of medication instructions in the EHR, such as when prescribers entered free-text instructions in the order comments field, which may go unnoticed by a pharmacist or nurse.
Recording on the Wrong Patient Chart: Another EMR documentation mistake is entering orders in the wrong patient’s chart. Though uncommon, this mistake usually occurs when patients share the same name. It poses a major patient safety hazard. For instance, if a medication order is transcribed onto the wrong patient’s chart it will result in the medication being administered to that patient. The Nurses Services Organization (NSO) recommends assigning a different nurse to each patient when there are two or more patients with the same name. The patient’s wrist band should be checked before giving medications. Organizations should also implement a system of identifying patients’ names and medication records.

Other Errors in Medical Records

Misplaced Documentation: According to the American Health Information Management Association (AHIMA) misplaced documentation concerns range from “data entered into the wrong field in an EHR to scrounging for missing pieces in a hybrid health record environment, misplaced information”. Common issues include misplaced progress notes, different providers using different terminology to explain the same condition, etc.
Not Completing the Medical Record within the Specified Time: Each patient’s condition and history of care should be recorded in a timely manner. There are specific time requirements for completion of each element in the medical record:
- History and Physical – completed and signed within 24 hours of admission
- Post-op note – written immediately after surgery
- Operative Note – dictated and signed within 24 hours of operation/procedure
- Medical Record – should be completed within 7 days of discharge or outpatient visit

Importance of Accurate Medical Documentation

Here are four reasons why accurate record patients’ medical information is essential:

To communicate with other medical personnel: Documentation explains the what, why, and how of providing clinical care to patients. These data give other medical professionals access to patient histories, enabling them to continue offering each patient the best care possible. Along the continuum of treatment, from EM to HM and transitioning into the post-acute care setting, proper documentation also aids in patient navigation and coordination.
Minimizes exposure to risk management: Accurate and thorough documentation lowers risk as well as the likelihood of a malpractice claim being upheld. In the event of a claim, having a thorough record of the patient’s care and treatment allays any worries about culpability. When you are in the middle of a professional liability claim and several years have passed, it is doubtful that you would recall the specifics of a particular instance. In this circumstance, your documentation will serve as your trusted ally.
Documents, PQRS Measures and CMS Hospital Quality Indicators: Documentation captures the data required to support value-based care measures that hospitals are increasingly required to report to government programs. This includes MIPS metrics and other hospital quality indicators, helping organizations meet healthcare documentation compliance.
Supports proper reimbursement: Accurate and thorough medical records can speed up payment, avoid hassles associated with claims processing, and support proper reimbursement and revenue cycle performance.

AI Medical Transcription Minimizes Medical Record Errors

AI medical transcription transforms clinician dictation into structured, clear, and consistent medical records. Advanced speech recognition systems trained in medical terminology accurately capture diagnoses, procedures, medications, and clinical notes, reducing omissions and formatting errors commonly caused by manual typing or rushed documentation.

AI-powered transcription tools also apply built-in quality checks, including terminology validation, contextual analysis, and error flagging. These capabilities help identify inconsistencies, missing details, and potential documentation errors before records are finalized. When paired with human review, AI medical transcription enhances documentation reliability, supports informed clinical decision-making, and promotes safer patient care.

Leveraging professional medical transcription services remains one of the most effective ways to ensure documentation accuracy. By combining certified medical transcriptionists with advanced automation, these services deliver timely, precise transcription that supports compliance, continuity of care, and revenue cycle efficiency.

Partner with a trusted medical transcription team today to ensure accurate, compliant medical records.

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

26-January-2023 MTS TEAM Medical Transcription

Clinical Documentation

Clinical documentation is the capture of clinical information at the patient encounter. Clear, accurate, consistent, complete, timely, and legible clinical documentation is necessary to reflect the patient’s condition and provide evidence that the care rendered was meaningful and medically necessary. Behavioral health providers, for instance, are required to document many types of notes from patient to patient and meet regulatory standards of practice and maintain appropriate, HIPAA compliant documentation. Outsourced medical transcription services can help therapists overcome the challenges of maintaining good clinical documentation.

Clinical Documentation in Behavioral Health

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

Psychotherapy notes or process notes: Mental health professionals maintain psychotherapy notes or process notes to document the details of the conversation during a private individual, group, joint, or family counseling session. These notes cover observations, the patient’s demeanor, hypotheses about a diagnosis, thoughts and feelings about the session, and questions. Psychotherapy notes are kept separate from progress notes. These notes cannot be released without authorization and excluded from the provision that allows patients to see their health information.

Progress notes: These notes include assessment, diagnosis, and treatment interventions, referrals, preventive services, and coordination of care with other healthcare providers. Progress notes more formal than process notes and include elements such as diagnosis, prescriptions and type of therapy with session dates and stop times, and all other components necessary for billing and reimbursement purposes. Providers should also document any unusual challenges the patient faced during the therapeutic process and how they were addressed. Progress notes must be objective, concise, relevant and well-written.

SOAP Expanded as Subjective, Objective, Assessment and Plan, the SOAP format is a widely used format structure for progress notes. It allows healthcare professionals to capture and communicate patient information from a session in a clear, concise way. Writing proper SOAP notes can go a long way in improving the quality of care.

SOAIGP: This format is more detailed than SOAP. SOAIGP expands to Supplementary Database Information, Observations, Activities with and on behalf of the patient, Impressions and Assessment, Goals and Plans for next actions by the worker and client.

BIRP: BIRP – Behavior, Intervention, Response, and Plan – is another option to document a patient’s treatment and progress. It allows therapists to organize their notes into these specific sections and ensure that patients who see multiple providers to get continual care.

DAP: DAP stands for Data, Assessment and Plan. This is one of the latest ways to write a psychotherapy or progress note. DAP notes combine the subjective and objective sections in SOAP notes into one comprehensive section. DAP notes allow therapists to quickly document individual and group psychotherapy sessions.

Group notes: Well organized documents are necessary for family therapy and other types of group sessions. In addition to the group summary and synopsis, therapists must document identifying information and details for each participant – from mood and body language, participation, issues between group members, objectives and goals for each patient and how they can achieve them to interventions, client feedback, and plans for future sessions.

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

DAP vs SOAP Therapy Notes? What Are the Differences?

Role of Mental Health Transcription Services

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

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

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

Documentation of large volumes of records in quick turnaround time: Experienced medical transcription companies can handle transcription tasks of any volume in quick turnaround time. Therapists capture information from a variety of sources: referrals, the patient interview, additional information received from other providers and family members. Details about the patient’s appearance, emotional expression, and affect, and their reactions or interaction with the therapist during the interview should also be noted. Capturing all of this information in individual and group sessions can be extremely challenging but crucial to provide targeted therapy. Outsourcing transcription to an expert is an ideal way to deal with this.

Accurate, detailed documentation: A thorough mental health assessment is necessary to collect all the details about a patient’s symptoms and complaints. This will enable proper diagnosis and appropriate treatment planning as well as help identify potential referral opportunities, so that the patients can benefit from the planned treatment. Qualified medical transcriptionists are familiar with the terminology, jargon and slang used in mental health services and can ensure accurate detailed documentation of mental health assessment for the medical record. This will provide the basis for the development of all other clinical documentation.

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

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

Best Practices for HIPAA Compliant Email Communication

23-January-2023 Julie Clements HIPAA Compliance

HIPAA Compliant

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

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

Importance of HIPAA-compliant Email for Physicians

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

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

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

Best Practices to Make Email HIPAA Compliant

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

End-to-end email encryption: In end-to-end email encryption, a set of keys is used to encrypt the email before it is sent and to decrypt the message when it is received and stored. So, the encrypted data can be read only by those with decryption keys – the intended recipient and the sender. This prevents unintended users from viewing or modifying data. AES 128, 192, or 256-bit encryption is the currently recommended standard for data security. Organizations should implement the safety measures best suited to their needs. Small medical practices that do not have in-house IT staff to implement HIPAA-compliant email can rely on a third-party HIPAA compliant email service provider.

Sign a business associate agreement with the email provider: Before using third-party service provider for end-to-end email encryption, physicians should have them sign a business associate agreement. The agreement should cover all the important points: how the company encrypts email, where the encryption keys are kept (onsite, offsite, or another server, etc) who has access to the encryption keys, how the company keeps the keys safe and handles physical security, and so on. In other words, the agreement should clearly define the email service provider’s responsibilities and the administrative, physical, and technical safeguards they will use to ensure the confidentiality, integrity and availability of electronic PHI. Don’t partner with a company that is not prepared to sign a business associate agreement.

Configure email correctly: Simply using an email service that is covered by a business associate agreement is not sufficient to make email HIPAA compliant. Email should be configured and set up correctly. Gmail helps users set up a HIPAA compliant email account using G Suite, provided the service is used alongside a business domain. Note that Google signs a business associate agreement only with paid users upon the request of a systems administrator. Subscribers must ensure that the service is configured to ensure end-to-end encryption.

Train staff on using email to exchange PHI: Practices should train staff on sending HIPAA compliant email and avoiding data breaches. They should strictly implement policies on email use to ensure that the right information is always sent to the right recipient using the necessary encryption methods. Every employee should be fully aware of their responsibilities and about avoiding errors such as sending PHI via unencrypted email or to individuals who are not authorized to view the information. Organizations should ensure that their email account has a strong password and two-way authentication to check unauthorized access.

Email retention: Retaining emails will allow providers to access and recover data in an emergency or during a compliance audit. While HIPAA rules don’t specifically mention email retention, they require covered entities to store documentation related to their compliance efforts for 6 years. Covered entities should maintain a backup email archive or ensure that emails are backed up and stored. Organizations should check if the laws of the state where they are located require emails to be stored for a fixed period of time.

Obtain patient consent: Organizations should obtain patient consent before they start using email to send PHI. Even if the email provider is HIPAA compliant, patients must be informed that there are risks to the confidentiality of information sent via their email service. Patients should also be told about the risks involved if they view email containing PHI on a public or unsecured network. Patient consent should be documented once they understand and accept the risks, and after this is done, healthcare providers can send emails containing PHI without violating HIPAA rules.

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

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