How Automation can Support Small Medical Practices

19-January-2023 Rajeev Rajagopal Medical Transcription

Small Medical Practices

Automation has disrupted many industries, and improved productivity by doing away with tasks that involve a high level of physical work and repetitive tasks. Healthcare is also benefiting from automation. One of the most common examples of automation in healthcare the development of voice recognition systems that instantly transform physician dictation into readable text. With speech recognition technology, the role of medical transcription services has morphed into editing machine-generated transcripts.

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

Processes That Small Medical Practices are Automating

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

Appointment scheduling: The front desk is a great place to start automation. Scheduling appointments and sending appointment reminders is a time-consuming and tedious task for front desk staff. When done manually, these tasks can involve spending hours calling up patients to arrange or rearrange time slots, even as patients are waiting in line at the practice. Leveraging automation for managing appointments can make a big difference to both patients and providers:
- correctly schedules/reschedules/cancellation of appointments without long wait times or confusion about dates
- allows patients to schedule at a convenient time, day or night, with no busy signals or wait on hold
- patient can make real-time updates to their appointment
- providers can set up auto-confirmations and appointment reminders
- enables high volume scheduling with consistent efficiency
- provides data in digital format

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

Data retrieval and sharing: Over the last decade, medical practices of all sizes have implemented electronic health records (EHRs) to provide care and obtain and share valuable data on patients. Today, EHRs are being integrated with advanced capabilities to generate data real-time, allowing providers to get the current, complete and accurate information they need instantly. Automation has improved EHR data retrieval and patient care.

Ordering and billing: Automation can be used to support key processes like ordering and billing. Predictive AI technologies can ensure that orders are completed with greater efficiency and speed. E-prescribing has become standard practice for many medical specialties. Prescriptions are sent to the pharmacy electronically from the point of care. E-prescribing can reduce the abuse and addiction rates of opioids and other controlled substances. Also, with electronic prescriptions, the EHR can automatically check for any potential drug reactions or allergies that could occur based on a patient’s current medication and diagnosis.

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

Practice management: Automating practice management with practice management software combines many functions and offers many advantages: streamlined processes and improved workflow across the entire practice, boost efficiency, and improved patient engagement and care. A well-implement, efficient system can grow your practice’s bottom line. As costly, incongruous systems can clutter operations and unnecessarily increase spending, a Medical Economics article recommends that practices should evaluate the software their practice uses and ensure it is working efficiently. If not, they should replace it with a cohesive, all-in-one solution.

Documentation tasks: Voice recognition technology is widely used to automate provider dictation and capture clinical information fast in real time. Best practice is for clinicians to document the patient consultation as close to the end of the appointment as possible. Even if they take brief notes, clinicians need to accurately describe the encounter. The main advantage of voice recognition is that it can be easily accessed from anywhere, anytime. However, as machine-generated documentation has possibility for errors, providers should ensure that it is vetted by a reliable medical transcription service provider.

Tracking patient health: Smartwatches, wearable medical devices, and smart thermometers collect data on pulse and blood pressure, heart activity, and temperature to identify illness and disease clusters. IoT (internet of things) enabled devices allow physicians to track patient health remotely and help them deliver care to keep patients safe and healthy. As with EHRs, healthcare providers should be aware about the data security concerns surrounding IoT.

Patient communications: Using chatbots is an effective way to answer common patient questions and to schedule appointments. Chatbots use machine learning and AI to simulate human communication, either through voice or text communication. During the coronavirus pandemic, chatbots were widely used in mental health care. Mental healthcare bots use cognitive behavioral therapy and apply techniques to help clients improve their mental health

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

Major Clinical Components of Dental Records

12-January-2023 Julie Clements Infographics

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

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

Dental Records

Different Components of Dental Records

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

Registration form: The registration form asks for specific information such as the patient’s name, address, work, and mailing address, among other things. Due to privacy concerns, a patient’s social security number will not be sought unless the office can demonstrate that it is required to utilize this number rather than an alternative specific identifier issued by the practice. If the office demonstrates a necessity, the practice must be able to protect sensitive information from intruders or computer hackers by blocking or encrypting it. The office will frequently need a Signature on File form if the patient is covered by insurance. When the patient or parent/guardian signs this, it allows billing to insurance without the patient needing to sign each time. This signature can be attached if it is gathered electronically.

Medical and dental history: Dental professionals must gather all essential and relevant medical information prior to beginning treatment in order to provide safe dental care. Medical and dental histories should be taken in a methodical manner, noting the patient’s current state of health as well as any major illnesses, ailments, or previous adverse reactions that could affect clinical therapy. Any significant dental history, such as an assessment of caries risk and periodontal health, must also be recorded in the patient’s report. Every patient is different, and while planning and sequencing dental care, the dental history should be taken into account alongside the clinical evaluation.

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

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

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

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

Ensuring Dental Record Accuracy

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

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

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

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

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

How to Prepare Different Types of Medical Transcription Reports

09-January-2023 Rajeev Rajagopal Medical Transcription

Medical Transcription Reports

A medical report provides a detailed account of a patient’s medical history, current condition, and treatment plan. Medical reports can be written by a variety of healthcare professionals, including doctors, nurses, and therapists, involved in a patient’s care. These reports help them track the patient’s progress, make informed decisions about treatment, and communicate with each other Medical transcription services ensure that this information is recorded and transcribed accurately and is easily accessible to all healthcare professionals involved in the patient’s care.

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

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

Medical Transcription Reports

Different Types of Medical Transcription Reports

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

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

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

Avoid Misinterpretations of Abbreviations in Medical Record Documentation

05-January-2023 MTS TEAM Medical Transcription

Medical Record Documentation

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

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

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

Problems Associated with the Use of Medical Abbreviations

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

Careless use of medical abbreviations and acronyms in the medical record

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

Common Medical Abbreviation Errors

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

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

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

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

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

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

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

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

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

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

APAP – acetaminophen: Not recognized as acetaminophen – Use acetaminophen

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

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

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

How to Avoid Misinterpretations of Abbreviations in Medical Record Documentation

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

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

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

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

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

How Medical Transcription Solutions can Optimize Physician Satisfaction

02-January-2023 Julie Clements Medical Transcription

Medical Transcription Solutions

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

Impact of Physician EHR Data Entry

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

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

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

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

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

Top Benefits of Medical Transcription Services

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

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

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

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

Transcribing Medication Orders

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

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

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

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

Medication Transcription Errors

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

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

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

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

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

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

Prevent Medication Documentation Errors with Outsourced Medical Transcription Services

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

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

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

Click here to learn more about our nursing transcription services.

Tips to Document Clinical Notes On Time [INFOGRAPHIC]

22-December-2022 Julie Clements Infographics

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

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

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

Check out the infographic below

Clinical Notes

How Can Physicians Find More Time To Provide Quality Care?

15-December-2022 MTS TEAM Medical Transcription

Quality Care

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

Need for Effective Time Management

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

Strategies for Physicians to Save Time for Patient Care

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

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

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

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

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

What Are The Main Parts Of Operative Notes?

12-December-2022 Julie Clements Medical Transcription

Operative Notes

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

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

What Is an Operative Note?

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

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

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Main Components of Operative Notes

Operative notes contain the following information:

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

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

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

General Principles of Operative Notes Documentation

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

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

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