Guidelines For Chiropractic Documentation

19-September-2022 MTS TEAM Medical Transcription

Chiropractic Documentation

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

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

Tips to Generate Accurate Chiropractic Records:

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

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

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

  • Assessment of the musculoskeletal and nervous systems via physical examination or x-rays:

    Identify how it was established that the patient’s pain when they first arrived was caused by a subluxation. Two of the four P.A.R.T. criteria-one of which must be asymmetry/ misalignment or range-of-motion abnormality-must be met in order to identify a subluxation based only on a physical examination.

    • evaluation of the location, nature, and degree of pain or soreness
    • a sectional or segmental level asymmetry or misalignment
    • abnormalities in range of motion
    • alterations in the properties of adjacent or connected soft tissues.
  • Diagnosis:
    • The primary diagnosis must be subluxation, including level of subluxation, either as expressed or indicated by a phrase that describes subluxation. Such words may refer to the state of the affected spinal joint or the direction that a certain bone is moving in.
    • To support the condition that led to the first diagnosis, secondary diagnostic is necessary.
    • Each level of the spine that is modified and invoiced for requires notes to validate these diagnosis codes.
  • Treatment plan:The following elements must be included in the treatment plan:
    • The recommended level of care (length and frequency of visits)
    • Specific treatment objectives
    • Evaluation of treatment effectiveness using objective metrics

Some Documentation Tips

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

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

Major Benefits Of Adopting A Specialty EHR

15-September-2022 Julie Clements Infographics

Electronic health record (EHR) requirements vary across specialties and every medical practice aims to achieve accurate and thorough EHR documentation. Electronic health records (EHRs) have vastly improved patient care coordination and delivery. Practices can now implement electronic health records for specialists that are flexible and help providers create a complete centralized patient record. Specialty EHRs work efficiently in all conditions and medical practices rely on medical transcription outsourcing to manage clinical documentation and focus on patient care.

Customized templates and a host of other features of specialty- specific EHRs can support workflows to meet the specific needs of medical specialists. It helps to promote error-free, timely documentation with functionalities like end-to-end documentation of patient notes, medical history, and lab reports. By integrating with the practice management software, a specialty-specific EHR can reduce no-shows, and improve patient satisfaction and engagement, scheduling, billing, payment processing, and communication. This highlights the major benefits of adopting a specialty EHR for medical practices, especially in today’s highly competitive healthcare environment.

While choosing a specialty- specific EHR, consider key factors such as – flexibility to meet the specialty’s needs, scalability, technology that improves patient engagement, secure HIPAA-compliant messaging, system architecture, seamless integration with relevant practice tools, real-time insights, and support for telehealth consultations.

Advantages of a Specialty EHR

EHR

  • Special features to cater to the niche: A specialty-specific EHR is an all-in-one solution that enhances the efficiency of the practice and allows the provider to manage all aspects of patient care. For example, ipatientcare.com lists the features of a cardiology EHR as:
    • Dashboard that comprises built-in MACRA for MIPS reporting to avoid penalties
    • Patient engagement portal and access to the practice with ability for patients to self-serve and make online payment securely
    • Extensive cardiology-specific templates with built-in cardiology specific codes
    • Checklist of past/present (CAD, IDOM, CVA and other heart conditions)
    • Diagnostic equipment interfacing
    • Medication tracking mechanisms
    • Palpation with PMI, heart sounds and pulse functions
    • Capability to identify patients for clinical trials
    • Manage reports

    Specialty- specific EHRs are flexible, operate efficiently in all conditions, and help providers create a comprehensive centralized patient record.

  • Improves the quality of patient care: Specialty-specific software improves the quality of care for patients. They can improve accessibility to patient records, allowing providers to evaluate key information pertaining to the patient prior to the scheduled appointment. For example, a quality cardiology EHR comes with add-ons like built-in checklists that ask patients for a full family medical history, which provides a comprehensive understanding of a patient’s health risks. This allows the specialist to process actionable information at all points, improve the clinical decision-making process, and meet the patient’s specific needs at a faster pace. Specialty EHRs can have a positive impact on the quality of patient care as well as the patient experience.
  • Improves workflow and processes: Most practices have uniform charting and workflow processes, but an EHR that is custom-built for a specialty will make charting and recording-keeping quicker, more accurate and efficient. This will have a direct impact on diagnosis and patient outcomes. For example, neurologists treat complex disorders and have unique requirements in the evaluation, diagnosis, management, and follow-up of patients. They can benefit from customized EHR solutions with modules for imaging, diagnostic testing, and streamlined data entry. In addition to detailed medical documentation of history and physical examination, a neurology-specific EHR would support specialty-specific neurophysiologic testing (e.g. electromyography/nerve conduction studies, EEG, evoked potential studies, neuroradiologic imaging (i.e. MRI, CT), and more. The neurologist can choose and set up modules and templates to automatically obtain patient data and add notes during the visit, eliminating errors and redundancies, and duplicate data entry. Overall, a customized system improves documentation and specialty-specific workflows and enhances practice productivity.
  • Saves time and eases specialty-specific clinician burnout: A specialty-specific system is designed to meet a particular specialty’s needs. It comes with templates and information for that specialty. As the study authors of a University of Texas Science Center in Houston study explained, “A bespoke EHR is an EHR custom designed to meet the unique needs of providers in a specific specialty or care setting. Bespoke EHR can prevent clinicians from spending a significant portion of their workday sifting through large amounts of clinical data for the specific data elements they need” (ehrintelligence.com/news). The study found that specialty-specific and physician-centered workflow improved clinical efficiency for users and delivered reports quickly. For example, while the average delay time for an EEG report is nearly 15 hours, the specialty-specific EHR delivered EEG reports on the same day.
  • Accurate documentation: Proper and detailed documentation of the clinical examination is crucial to accurately diagnose and follow the progression of complex neurological disorders. Specialty-specific EHR software is designed to promote error-free, timely documentation with functionalities like the end to end documentation of patient notes, medical history, and lab reports. Medical transcription providers support the process with customized documentation for all major medical specialties and sub-specialties.
  • Integration with other office systems: Custom EHRs can integrate with the other practice software, which simplifies implementation, improves clinical workflow, and supports efficient billing workflow, communication, and patient engagement. This demonstrates the strong role of specialty EHR in streamlining clinical workflows, from billing and scheduling to patient engagement. By integrating with the practice management software, a specialty-specific EHR can reduce no-shows, and improve patient satisfaction and engagement, scheduling, billing, payment processing, and communication.
  • Meets specific billing requirements: Physicians providing specialized care have different medical billing and coding requirements. EHR systems with specialty specific features offer access to templates and codes relevant to the provider’s niche, allowing easy reporting with specific ICD-10 codes to identify the reason for the visit. By automating processes such as scheduling, billing due dates and patient tracking, these value-added systems allow physicians to focus on delivering high-quality care rather than cumbersome administrative tasks.

Choosing a Specialty EHR – Key Considerations

The best specialty EHRs include the advanced features described above. Keep the following considerations in mind when choosing a specialty EHR:

  • Flexibility to meet your specific needs
  • Scalability to accommodate all the providers in your practice
  • Technology that improves patient engagement
  • Secure HIPAA-compliant messaging to enhance patient-physician communication
  • System architecture – Must be directly installed on computer servers and accessible from anywhere
  • Seamless integration with relevant practice tools
  • Real-time insights
  • Support for telehealth consultations

Specialty EHRs are built with custom features, reports, and templates to match personalized needs. Proper EHR training and education are essential to optimize the use of these systems. Medical transcription outsourcing to a company that provides custom EHR documentation solutions for healthcare specialists can help providers streamline and coordinate effective care.

Choose medical transcription outsourcing today and let experts handle the paperwork while you focus on delivering healthcare services!

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What Are the 15 Main Components of a Complete Medical Record?

12-September-2022 Rajeev Rajagopal Medical Transcription Outsourcing

15 Main Components of a Complete Medical Record

Medical records are a crucial resource containing all the information about a patient’s health condition, medical history and other vital data. The medical chart contains provisions and rights that prohibit the information from getting into the wrong hands or being disseminated unlawfully. They are both medical and legal documents. Therefore, the most effective method to create accurate medical records is to use a medical transcription service.

Traditionally, medical records were documented on paper with tabs dividing the parts. Reports were transferred to the appropriate tab once they were printed out. These components are still included in the electronic patient record, and they are now accessible electronically with the help of medical transcription and EHR.

What Is a Medical Record and Why Is It Important?

A patient’s medical history and care are systematically documented in a medical record. The patient’s health information (PHI), which includes identity data, medical examination results, and billing data, is typically contained there. The U.S. Department of Health and Human Services states that only a person or that person’s personal representative may have access to these sensitive documents.

From patient to patient, there will be a big difference in the amount, type, and degree of information included in their medical record. The amount of care a patient needs will mostly dictate what documentation is needed. Therefore, it’s important to familiarize yourself with what exactly is contained in them as well as your legal rights in relation to such vital information.

It is also necessary for business professionals who might need to obtain medical records to become familiar with these records and comprehend their fundamental structure. The patient’s health and wellness, as well as any information that can improve care, are better understood by future and existing health providers with the help of this valuable data. However, this is not the only use of medical records. Depending on the case, medical records may be useful in legal proceedings. Without the subject’s permission, access to these records is prohibited.

However, getting hold of medical records for legal answers might be a challenge. The process can be expedited by using a good medical document retrieval service. Similarly, medical records are also necessary to process a person’s health insurance claims. In order to ensure that the medical expenditures match the claims that are made, insurance companies request medical evidence while analyzing claims.

So, now that we have highlighted the significance of having accurate medical records, let us consider the components of a medical record.

Legal Significance of Having a Medical Record

Medical records have crucial legal significance, serving as comprehensive documentation of a patient’s medical history, treatment plans, and healthcare decisions. In legal contexts, these records are essential as they provide objective, detailed accounts of patient care, which can be pivotal in medical malpractice cases, insurance claims, or personal injury lawsuits. Medical records can confirm timelines, treatments administered, and physician recommendations, creating a clear narrative that helps determine whether standard care was provided. They also play a key role in defending healthcare providers by showing that appropriate procedures were followed, supporting them against allegations of negligence. Given their sensitivity, accurate and confidential handling of these records is essential to protect patient privacy and comply with healthcare regulations, such as HIPAA.

Key Elements of a Medical Record

Comprehensive Medical Record

  1. 1. Patient Information Form: This document is filled out by the patient on their first visit to the doctor’s office and updated as needed. It contains information that is directly related to the patient, such as their last name, first name, gender, DOB, marital status, street address, city, state, zip code, telephone number, social security number, employment status, employer’s address and phone number, and name and contact information for the person who is responsible for them.
  2. 2. Medical History: This document outlines any medical ailments the patient has had in the past as well as those he or she has at present.
  3. 3. Physical Examination: A complete head-to-toe evaluation of the patient’s physical state is included in the physical examination (PE) record.
  4. 4. Consent Form: It is a signed statement from the patient or guardian approving the course of treatment.
  5. 5. Form of Informed Consent: It is a written statement detailing the goals, dangers, and advantages of an operation that is signed by the patient or legal guardian, and acts as evidence that the patient was properly informed before having the treatment or procedure done.
  6. 6. Doctor’s Orders: It includes a list of the procedures, medicines, therapies, and other prescriptions for a certain patient.
  7. 7. Nursing Records: In these records, vital indicators including blood pressure, temperature, pulse, and respiration, of the patient are recorded.
  8. 8. Progress Reports from the Doctor: It is the documentation provided by the doctor outlining the patient’s condition, the outcomes of the doctor’s assessment, summary of the test results, the treatment plan, and any necessary data updates.
  9. 9. Reports on Consultations: It is documentation provided by experts the doctor contacted to evaluate the patient.
  10. 10. Additional or other Reports: These maintain a record of treatments or procedures given to patients, such as chemotherapy, respiratory therapy, or physical therapy.
  11. 11. Diagnostic Procedures and Lab Results: These comprise documents containing the findings of every diagnostic test and laboratory procedure that the patient underwent.
  12. 12. Operative Report: It has the surgeon’s written account of the process, including the preoperative and postoperative diagnoses, the precise specifics of the surgical procedure, the patient’s response to it, and any complications that may have arisen.
  13. 13. Anesthesiology Report: It includes information from the attending anesthesiologist or anesthetist that provides a thorough account of anesthesia during surgery, including the drugs used, their dosage and administration time, the patient’s reaction, the monitoring of vital signs, how well the patient tolerated the anesthesia, and any complications that may have arisen.
  14. 14. Pathology Report: The findings or outcomes of samples taken from the patient, such as bone marrow, blood, or tissue, are documented in the pathology report. Pathology transcription converts all pathology records into precise transcripts.
  15. 15. Discharge Summary: A summary of the patient’s hospital care, including the date of admission, the diagnosis, the course of treatment and any responses from the patient, the outcomes of the tests, the final diagnosis, the follow-up plans, and the date of discharge.

For medical practices, hospitals and healthcare units, it is important to keep their medical records accurate and up-to-date. With so many patients flowing into your healthcare organization, it is best to utilize HIPAA-compliant medical transcription service to streamline medical documentation. They also understand the key elements that constitute the medical records. A complete and accurate medical chart means good patient care and optimal treatment outcome.

Enhance your medical record accuracy and ensure legal compliance with expert medical transcription services.

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Strategies To Streamline EHR Documentation For Telehealth Visits

01-September-2022 Julie Clements EHR Transcription

EHR Documentation

Electronic health records (EHRs) allow physicians to manage clinical information in an effective way and share patient data with other health providers. Outsourcing medical transcription helps them ensure timely and accurate EHR documentation. Remote medical consultations became an effective tool for patient interactions and care during the pandemic. Recent reports say that the demand for video medical visits is likely to continue to increase. As Seema Verma, Administrator of The Centers for Medicare and Medicaid Services (CMS) stated, “the genie is out of the bottle on this one” and there’s no going back on telehealth.

Telehealth Visits are Burdensome for Physicians, say Studies

While virtual consults are a convenient, cost-effective option for patients, recent studies found that physicians are working after-hours to complete EHR-based clinical and administrative work, including documentation, leading to burnout. The authors of a study published in Perspectives Health Information Management in January 2022 reported that “current practices in telehealth documentation are progressing toward but not yet completely meeting best practice goals”. The study noted that the rapid adaptation of telehealth within the last 18 months and the uncertainties in related documentation standards have left many without clear guidelines.

MobiHealthNews reported on another recent study that was published in JMIR in July found that time spent on work-related tasks outside clinical hours, often referred to as “work outside work” (WOW), increased “significantly” for those physicians who spent a larger proportion of their time providing care via telemedicine. The study, which covered 2,129 physicians, was conducted at New York University Langone Health. “Taking physicians’ clinical load into account, physicians who devoted a higher proportion of their clinical time to telemedicine throughout various stages of the pandemic engaged in higher levels of EHR-based after-hours work compared to those who used telemedicine less intensively,” the authors concluded. “This suggests that telemedicine, as currently delivered, may be less efficient than in-person-based care and may increase the after-hours work burden of physicians.”

The good news is that there are various options to streamline and optimize EHR documentation for telehealth visits.

Best Practices to Optimize Telehealth Documentation

  • EHR telehealth integration: Integrating a telehealth platform into the EHR and patient portal can ease clinician burden and ease documentation. With standard EHR design, physicians need to click through multiple screens and form fields, diverting attention from the patient. Though modern cloud-based telehealth platforms are focused on the provider experience, fatigue and digital overload still persist. It has been found that the solution lies in integrating telehealth and EHR technology.

    With an EHR-integrated solution, physicians can avoid making multiple clicks to navigate between documentation and video screens. When all the data is integrated on one platform, clinicians can view the patient’s journey map on a “single pane.” This decreases cognitive workflow and reduces clinician burden, explains David West, MD, medical director of health informatics at Nemours Children’s Health (ehrintelligence.com).

    Other benefits of integrating telehealth and EHR technology according a www.telemedmag.com report include:

    • Creates simplified and seamless virtual care workflows that offer the same validity as face-to-face patient/provider interactions
    • Enhances the patient’s telehealth experience – they can understand their diagnoses better, and view their history when the session is complete
    • Enables physicians to verify patient eligibility, which is important for claim submission and reimbursement for services
    • Avoids duplicate entries (in the EHR and telehealth system), reduces risk of errors and improves clinical efficiency
    • Streamlines patient care in one single clinical workflow, making patient check-in and interactions easier for staff

    So, an integrated solution provides many benefits for both providers and patients.

  • Setting up a second screen: While EHR telehealth integration brings the patient journey visible on a single pane, it is not available everywhere. Adding a second screen via a laptop or tablet is a practical option in this situation. The American Academy of Family Physicians (AAFP) recommends using a second screen to make documentation easier during a telehealth consultation. The physician can use the primary screen for the telehealth camera and the electronic health record (EHR), and the second screen for viewing the patient in real time. This arrangement makes it easier for the physician to enter data in the EHR while looking at and talking to the patient.
  • Using voice recognition technology: Speech recognition technology (SRT) is used by many providers to manage EHR documentation. With surging patient volume during the pandemic, the use of this EHR scribe solution surged, improving workflow efficiency.

Other best practices that the Perspect Health Inf Manag. study recommends to streamline telehealth documentation include:

  • Supporting telehealth billing requirements and training medical students on documentation guidelines for telehealth services
  • Calculating visit time correctly
  • Modifying note templates in the electronic health record to meet telehealth documentation requirements
  • Developing procedures and forms to make documentation as streamlined as possible
  • Prioritizing continuous monitoring of the guidelines on telehealth documentation from national and discipline-specific organizations
  • Fostering compliance by updating policies and procedures to include telehealth chart audits

Outsource Medical Transcription

Outsourced medical transcription services can improve the efficiency of all the above-mentioned strategies and reduce clinician stress. Experienced service providers deliver EHR-integrated transcription solutions, including review of SRT-generated transcripts.

Telehealth is here to stay and every practice needs to adopt the right strategies to streamline the documentation of remote medical visits. With the shift to value-based care, the importance of a team-based approach has also increased. Seamless data sharing can promote proper care coordination, care quality and outcomes, not only among nurses, care managers, and other clinical staff in a facility but also with specialists across geographies. Outsourcing medical transcription can ensure quality data for sharing across various setting and the health care continuum.

How To Ensure Accurate Pathology Documentation With Medical Transcription Service

29-August-2022 Rajeev Rajagopal Pathology Transcription

Medical Transcription Service

Pathologists are medical professionals that diagnose and research diseases using a variety of laboratory techniques. With the aid of medical transcription services, conversations between doctors, pathologists and patients, and medical histories and other vital information, can be recorded and transcribed. For the benefit of the medical specialists and the patients, these recordings must be transformed into text format accurately and also flagged if there are any discrepancies.

What is a Pathology Report?

A pathology report is a medical analysis of a body organ, blood sample, or piece of tissue that has been removed from a patient’s body. A pathologist examines the samples and then compiles a report for the healthcare professional who either requested the report or had the treatment done. The healthcare professional will use pathology reports to make a diagnosis and develop a treatment strategy for a particular illness or condition.

The majority of pathology transcription service entails typing descriptions of surgical specimens from tissue samples that are taken using biopsies. Pathologists need to transcribe medical records and patient reports from larger samples taken from the patient’s body. Most of the reports are only a few sentences long usually, but they all matter. Therefore, it is essential to accurately record pathology results in order to deliver appropriate and excellent patient treatment. A patient may suffer if a pathology report is erroneous or incomplete.

How to Document a Pathology Report

A pathology report is a crucial document that directs decisions regarding diagnosis and prognosis. Therefore, it is essential to accurately record pathology results in order to deliver appropriate patient treatment. Patient treatment can suffer from incomplete and inaccurate pathology results and even a small typographical error can significantly alter a report’s interpretation.

So, to generate an accurate radiology report, it is important to understand what constitutes a pathology report.

  • Identification data: The patient’s name, the hospital-issued medical record number, the date of the biopsy or surgery, and the specific specimen number are all included in the general identifying information and this is assigned in the lab.
  • A clinical report: The doctor who extracted the tissue sample will usually provide information on the patient in the report’s following section. A medical history and any particular requests made to the pathologist may be included here as well. For instance, if a lymph node sample is being taken from a patient who is already known to have cancer in another organ, the doctor will record the type of the original disease. This knowledge is often useful in assisting the pathologist to decide which specialized tests may be required to determine whether any cancer in that lymph node is a metastasis (spread) from the primary disease or a new cancer that developed in the lymph node.
  • Gross description: The gross description is the name of the report’s next section. “Gross” in medicine refers to something that cannot be magnified. The pathologist only needs to look at, measure, and feel the tissue sample to see this. This description for a tiny biopsy consists of a few phrases that list the sample’s size, color, and consistency. The quantity of tissue-containing cassettes submitted for processing is also tracked in this area. Larger biopsy or tissue specimens, like those from a mastectomy for breast cancer, will have much longer descriptions that include the size of the entire piece of tissue, the size of the cancer, how close the cancer is to the closest surgical margin (edge) of the specimen, the number of lymph nodes found in the underarm region, and the appearance of the non-cancer tissue.
  • Diagnosis: The final diagnosis is the most significant component of the pathology report. Although this section may be at the top or bottom of the page, it represents the “bottom line” of the testing procedure. This final diagnosis is used by the clinician to guide selection of the most appropriate course of treatment. If cancer is the result of the diagnosis, this section will specify the specific type of cancer and typically describe the malignancy’s stage.
  • Comment: The pathologist may want to provide additional details for the treating physicians when the definitive diagnosis is reached. The comment box is frequently used to address questions or suggest additional testing.
  • Summary: Some pathology reports for tumors include a summary of the findings that are most crucial for choosing a course of treatment.

Accurate pathology transcription is essential for healthcare providers as well as the patient’s peace of mind. By giving important medical information in clear, concise writing, medical transcription services can significantly reduce the strain placed on medical practitioners. A reliable transcription provider provides HIPAA-compliant transcription that streamlines your workflow and allows for the fastest turnaround times available. They complete your anatomical or clinical reports anywhere from a one-hour turnaround time to 24-hour turnaround times.

Study: Lengthy EHR Notes Contributing To Physician Burnout

25-August-2022 MTS TEAM EHR Transcription

Physician Burnout

Effective healthcare documentation is crucial to convey clinical information about a patient’s diagnosis, treatment, and outcomes, for communication between clinicians and payers, and to avoid compliance issues. Outsourcing medical transcription is a widely accepted strategy to ensure complete and accurate electronic health record (EHR) documentation and ease physician burnout. In fact, several studies have reported that physician stress and burnout are directly linked to EHRs. According to a recent study, EHR progress notes are becoming lengthier and more redundant in all specialties, increasing clinician burnout concerns.

Templates Undermining the Value of the EHR

The research, which was published in JAMA Network Open, was based on a study of 2.7 million clinical progress notes created by 6,228 clinicians and staff members at an academic medical center between 2009 and 2018.  The researchers found that in the decade since EHRs were adopted in 2009, median note length increased 60.1 percent, from 401 words to 642 words. Other findings of the study:

  • Median note redundancy (the proportion of text identical to the patient’s last note), increased from 7.9 percent to 58.8 percent, by 10.9 percent.
  • Newer employees (residents and fellows) wrote 26.3 percent longer notes than more senior employees.
  • Each year after an author started using the EHR saw a 1.8 percent increase in note length.
  • EHR clinician notes that had a higher proportion of templated or copied text were significantly longer and more redundant.
  • In all specialties, less than 50% of note text was directly typed in 2018. In 36 specialties, less than one-third of note text was directly typed in.
  • Up to 55.9 percent text written in 2018 was templated as compared to 14.7 percent which was copied.

Templates may be taking away from the value of patient health records, according to the study. The researchers wrote: “Templates can reduce documentation time and increase standardization, but can also add potentially irrelevant information or introduce errors, as when used to insert default examination findings which were not actually observed.”

The researchers concluded that patient care notes have become lengthier and more redundant since electronic health records were adopted in 2009. The two key findings of the study are:

  • A major proportion of note text is templated or copied
  • Residents, fellows, and more recent hires write significantly longer notes

Another study published in 2018 analyzed similarity in progress notes from successive outpatient ophthalmology encounters. This study also found that content importing technology results in duplication of large amounts of clinical text in EHR progress notes. The key points highlighted by the researchers are as follows:

  • The average ophthalmology progress note is long.
  • The major portion of each note subsection is identical to prior notes.
  • Important note sections make up a small portion of overall length.
  • EHR content importing technology has made it more difficult for physicians to find the most important sections of the note.
  • Copied text may be outdated or internally inconsistent and the errors may propagate throughout subsequent notes.
  • Redundant information makes it difficult to distinguish between current and historical data, and when and by whom the documentation was first written.
  • Reading longer progress notes takes more time.

The researchers noted that importing large amounts of EHR data may reduce the reliability of the medical record. 

Institutional Policies and EHR Redesign can make a Difference

Institutional policies can make a difference by encouraging brief, succinct progress notes and restricting the use of templates that import medication lists or past medical history. Such information is associated with a patient encounter but should be kept separate from the main body of the progress note text.

EHRs should be redesigned to limit the amount of computer-generated text inserted into the progress note. Billing and other information that is not directly related to patient care should be kept separate from clinician-generated text or displayed only on demand instead of by default. EHRs should also provide physicians with more control over how and where important information is displayed.

How Medical Transcription Outsourcing Helps

Partnering with a medical transcription company to aid with documentation can decrease clinician burden. Experienced medical transcriptionists can ensure accurate and timely EHR documentation. With a reliable company handling their EHR documentation tasks, physicians can focus on strengthening relationships patients and optimizing care.

Best Medical Transcription Companies Of 2022

22-August-2022 Julie Clements Medical Transcription

Medical Transcription Companies

Healthcare practices generate a lot of notes daily, ranging from clinical documentation of patient encounters and patient records to administrative notes. Transcribing patient exam notes and other reports, mainly after long hours of consultation will be difficult for providers as well as their front office staff. Setting up an in-house team is quite expensive and is not practical, mainly for small practices. Most practices today consider medical transcription outsourcing, as it is a cost-effective and faster option to get accurate transcripts for the voice recording of any records. Outsourcing medical transcription tasks can save time and improve the accuracy of clinical documentation and other written records.

Take a Look at Some of Best Medical Transcription Companies 2022

1. MOS Medical Transcription Services

MOS

 

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One of the leading medical transcription companies in the U.S., MOS Medical Transcription Services has a strong track record of providing excellent services for practices in almost all specialties since 2002. Committed to providing HIPAA-compliant medical transcription services for healthcare providers in the U.S., the company provides services of experienced and qualified transcriptionists and editors to create and deliver accurate transcripts. They can interface seamlessly with any practice’s EHR/EMR system. With their service, practices can benefit from free trial offer, standard 24-HOUR TAT and STAT options, no setup or hidden fees, no long-term contracts, 3 levels of quality assurance, secure file transfer, flexible dictation options and more.

2. InSync Healthcare Solutions

insync

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Along with medical transcription, editing, dictation, and virtual scribe services, the company also offers multiple EHR solutions (CareLogic, Credible, and now InSync) to clinics and practices serving over 10 million patients in all 50 states. They ensure highest documentation quality and accuracy standards to achieve more complete reimbursements. Whether providers are utilizing in-house transcriptionists or outsourcing their transcription through a third party vendor, InSync can provide either a full or partial outsource of work—by job type, provider, or department.

3. Aquity Solutions

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The company provides highly cost competitive onshore and offshore transcription services that are enabled by unparalleled quality checks. Their clients can benefit from unparalleled process visibility, workflow control, multiple price points, automated reporting and cost management. Practices can easily track transcription influenced Key Performance Indicators (KPIs) through their unique reporting and workflow analytics.

4. EHR Transcription

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The company provides 100% online medical transcription services that provides secure access for practices from anywhere. Based fully in the United States, it assures no lost or late transcription, no sloppy transcription or lame excuses. Providers can send their dictation via a free telephone account, digital voice recorder, computer microphone, or iPhone app. To ensure accuracy, transcripts are checked with manual reviews, followed by an automated spelling/grammar check, before being human-proofed again.

5. DataMatrix Medical

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Their transcription programs are custom made to fit the unique needs of each individual practice. Each physician will be provided with a team of medical transcriptionists who are trained to input data seamlessly into the EHR system. For practices already using voice recognition software as a dictation method, the company also offer a proofreading services for notes already dictated. The company’s medical scribes listen to the audio recordings and review them within the practice’s EHR software. They also follow data security protocols to ensure patient privacy.

6. SMARTMD

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SMARTMD transcribes dictated notes directly into the patient’s chart by the next morning, saving everyone time and getting the most out of the practice’s EHR. They also offer an online archive of transcriptions in a secure cloud account that provides access to 2them from anywhere and at any time. The company uses a workforce of American-based transcriptionists and offers a free trial option.

7. The Dictation Source

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This U.S. based medical transcription solutions provider offers hyper-accelerated, accurate clinical documentation through an advanced platform that deploys automation. Their prices range from 7.5 cents to 10 cents per line. The company can integrate medical notes into pre-existing templates and/or letterheads at no additional charge. Clients can also directly access completed documents and make any changes online in any operating platform (Windows, Mac, Linux).

8. Acusis

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Acusis provides HIPAA & HITECH compliant services along with the highest possible levels of security, to protect the sensitive medical data. The company uses eCareNotes transcription platform for speech-enabled transcription workflow. This platform is ideal to optimize transcription workforce, reduce operational cost and improve quality. Practices can easily upload their audio files through a traditional telephone line or through an iPhone app.

It is important for providers to choose a medical transcription services company that can provide fast, accurate, affordable and secure solutions. While choosing a medical transcription service company, consider key factors such as accuracy, associated costs, turnaround time, quality assurance process, free trial and more.

How Medical Transcription Services Help In Settling Insurance Claims

18-August-2022 Rajeev Rajagopal Medical Transcription

Medical Transcription Services

Many individuals rely on health insurance funds to meet their medical expenses. It is painful to see a patient forgo necessary care because of the high expense involved or because a treatment is too expensive for them. It is very frustrating if the insurance claim is not settled or the payment is delayed.  The main reason for delayed and denied claims is usually the lack of clarity in the medical records and medical claims. This issue can be effectively addressed if physicians hire a professional medical transcription service to ensure accuracy of the medical records.

Verifying medical data is a crucial step in the medical insurance claim settlement process and for that reason, accurate transcripts are the most trustworthy documents. These may be used as proof in court if there is a dispute over payment of claims between patients and insurance companies. As per HIPAA also, retaining good medical records has become crucial to the delivery of healthcare. Doctors are required to create comprehensive documentation detailing the treatment they give a patient. Medical transcription is done in accordance with HIPAA regulations.

Why Medical Transcription Is Important for Physicians and Health Insurers

Settlement of insurance claims is highly complex. To prove that a claim is true and not fabricated, accurate medical documentation must be made available for the insurer. Therefore, there is considerable demand for precisely transcribed medical records. By digitizing the consultation reports for invoicing, record-keeping, and insurance claims, the transcriptionists can lessen physician and in-house workload. They assist in the digital transcription of:

  • Consultation reports:  Consultation reports are used to outline the patient’s past experiences as well as the reason for providing a particular treatment. It is a concise report that explains the patient’s situation and also contains all the basic information of the patient.
  • Discharge summary: When a patient leaves the hospital, a discharge statement is essential. Hospital discharge summaries are the key documents used to communicate a patient’s treatment plan to the post-hospital care team.
  • Operative notes: An operative note is a report that is included in a patient’s medical file to summarize a procedure. Following a surgical procedure, the operative report is dictated and then entered into the patient’s file.

Accurate Medical Records for Insurance Claim Adjusters

When an injury claim is filed with a health insurer, an insurance claim adjuster initially looks into it to determine the full extent of the at-fault party’s liability. He interacts with the claimant, carefully examines all the evidence-supporting papers, speaks with additional witnesses, and then produces a report based on his findings.

A smooth resolution of an insurance claim is guaranteed by accurately recorded insurance reports. The claim adjuster is a specialized official hired by insurance companies to study the case and document the entire procedure from start to finish. His duties include comprehending the severity of the injuries, the justification for the compensation amount requested, investigating the legal ramifications, and comparing the information to the actual insurance policy. He will have to look over the patient’s medical history, expenses, and reports of the most recent injury for which the patient was admitted to the hospital.

The claim adjuster asks copies of the claimant’s medical records when there is a medical emergency, such as a car accident or unexpected death, in order to determine the underlying reason.

It is crucial that the claimant has legal backing for his/her claim, and in order to do so, the language in their medical reports must be accurate. This accuracy in medical documentation is what medical transcription services ensure.

How Insurance Companies Use Medical Records

  • Verifying the accuracy of application information: Before issuing a policy, insurers frequently ask applicants to undergo a medical examination and/or provide medical records. They validate all the information submitted in an application using this medical data. These are also used to see if any relevant information, such as family medical history or any pre-existing conditions, was left out.
  • Calculating the value of claims: Claims adjusters thoroughly go over medical documents when it comes to plans like individual disability income insurance or long-term disability insurance to comprehend the scope and seriousness of a claimant’s ailment. This enables them to assess a claim’s value. Claimants who are unable to work owing to an incapacitating illness or accident, may receive good compensation. However, if medical records show that the damage or condition isn’t particularly serious, the claim can be reduced or even rejected. In order to stop paying benefits, adjusters also periodically evaluate medical records for any changes that would indicate that the claimant is no longer disabled.
  • Insurance companies need quick retrieval of medical records: The process of getting medical records must be rapid and precise due to the critical role that they play in how insurers do their jobs. Insurance companies may hire professionals from reliable medical transcription services to handle the retrieval process.

One of the best ways to ensure timely reimbursement of insurance claims and settlement is to generate accurate medical records at the right time. A professional medical transcription company can help healthcare professionals generate and manage error-free medical records.

Why Healthcare Organizations Need A Blended Approach Of Medical Transcription Service And EHR

15-August-2022 MTS TEAM Medical Transcription

Medical Transcription Service

Healthcare organizations are constantly looking for ways to improve patient care and reduce costs. Adopting a blended approach – EHR systems along with medical transcription services is an excellent way to accomplish this goal. With the electronic health record, clinicians are forced to spend more time in front of the computer instead of treating the patients. However, medical transcription solutions play the role of a savior in assisting practitioners to boost productivity.

Ready to enhance your clinical documentation accuracy and boost physician productivity?

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Relevance of Medical Transcription

EHR is a useful tool for keeping track of the patient’s medical information. It is a practical and well-organized way to guarantee accurate patient data. Despite the fact that the EHR has many advantages, healthcare providers are concerned about this electronic record-keeping system.

One of the most important barriers to the implementation of Electronic Health Records (EHR) systems is related to difficulties that physicians face in capturing the patient narrative (especially because of the structured templates of EHRs). When it comes to having successful conversations with their patients, they find it to be both distracting and an undesirable imposition. Many healthcare professionals complain about their inability to provide high-quality patient care and the general inefficiencies of their office operations. This process takes up a lot of the consulting time and is laborious and time-consuming. Sometimes, doctors misuse the copy-paste feature of the EHR, which leads to inaccurate documentation of medical information and ineffective operation of healthcare facilities. This procedure poses some limitations to the efficient use of EHR technology.

  • Limitations of templates and checkboxes – The checkboxes or templates in the software are such that they cannot capture patient information in a comprehensive manner.
  • No quality checks – Since the patient health record is a valid legal document, validation of the content is essential.
  • Low physician productivity – Self-editing dictation and filling out templates would lower physician productivity and reduce the total number of patients seen in a day.

From a practical point of view, medical transcription remains a vital component of clinical documentation workflow. The solution to ensuring efficient clinical documentation and improved patient care, say experts, is a blended approach which combines transcription with EHR.

A Blended Approach Could Be Ideal

A combination strategy using both medical transcription and EHR could be helpful to overcome all these shortcomings. Doctors can dictate their notes into a recording device, and the digital equipment will clearly record everything. This audio data is encrypted before being forwarded to skilled medical transcriptionists, who turn them into accurate transcripts that are then incorporated into the doctor’s EHR. This combination strategy’s key benefit is that it both complies with the government mandate to install EHR and ensures correct clinical documentation. It enables doctors to engage with patients more, and concentrate on providing higher-quality care.

The medical transcription workflow that blends an outsourced solution with the EHR system would involve the following steps:

  • The physician dictates via phone or other handheld device.
  • The digital voice files are clearly captured, encrypted and delivered to servers.
  • Trained medical transcriptionists who are experts in clinical documentation listen to the dictation and create the files.
  • The transcribed files are integrated into the EHR utilizing the latest technology.
  • Integrated patient records are made available to the healthcare provider.

EHR and Medical Transcription

Advantages of a Blended Approach

  • More time for your patients: No matter how proficient you are with EHR, it can be challenging to keep up while a patient is detailing his or her symptoms, therapies, and more. However, a medical transcription service would enter the transcript of what is being said into your EHR more professionally and quickly. When the documentation part is taken care of by the transcriptionist, physicians can dedicate quality time to their patients, and patients will feel heard, which is essential to ensure overall patient satisfaction.
  • Minimize the chances of document errors: Reduce documentation errors by outsourcing your electronic health records to a proficient transcriptionist. If the transcription of your dictated notes is done in-house, there are more chances of typos or other mistakes in the documentation. These mistakes take a long time to correct, and if they are not discovered right away, they may have more serious ethical repercussions. However, having professionals do the transcription for you ensures documentation that is more accurate and reliable.
  • Better patient care: Every clinic strives to provide better patient care. You can do it by combining medical transcription and EHR. The key to enhancing patient care is better, more accurate recordkeeping. Doctors will be able to treat their patients appropriately if the documentation is accurate and reflects the patient’s needs for care. Additionally, digital dictation is used in patient care. Your doctors can spend more time with the patients when they hire a medical transcription service to handle their dictations. The quality of overall patient care is increased by this one-on-one engagement.
  • Relieves doctors from point and click work: There are several buttons to click and boxes to tick on the EHR. Physicians may tick boxes and click buttons they shouldn’t because they are already pressed for time, which could lead to bigger and more significant problems. By taking care of the point-and-click labor that physicians must do, medical transcription and EHR can be combined to minimize errors. This enhances patient information and EHR utilization as a whole.
  • Improved referrals among doctors: You might observe more physician referrals when your EHR is combined with a medical transcription service. When implemented properly, EHR streamlines the exchange of patient data between clinics. When a patient needs a specific approach to care, this is extremely beneficial. Your EHR records will be simpler to understand and navigate when a medical transcriptionist is working with them. This simplifies the referral process, which benefits both the patient-provider relationship and the relationship between the providers.
  • Quick reimbursement: Nearly every practice has a problem with payment for services. EHR and medical transcription integration, however, can assist with that. Billing will be more accurate if your records are more accurate. Because of the increased billing accuracy, your clinic can pursue reimbursement more quickly, which gives you time to deal with late or lost payments. The care of patients is also impacted by quicker reimbursement. You may put more money toward enhancing patient care when you have more money to expand your practice, buy new tools, and do other things.
Do you know why medical transcription is important for your healthcare facility? Read our blog post 5 Ways in Which Medical Transcription Is Important in a Hospital Setting

Medical professionals can quickly and safely complete their medical documentation using EHR-integrated medical transcription services. This integrated strategy aids in raising revenue and boosting productivity. It enhances productive work flow and guarantees that each patient visit is properly documented.

Maximize your clinic’s efficiency and improve patient outcomes by combining medical transcription with your EHR system.

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Key Tips To Improve Nephrology Documentation

11-August-2022 Julie Clements Nephrology Transcription

Nephrology Documentation

Proper healthcare documentation is necessary to promote safe and effective patient care, meet compliance, and receive appropriate reimbursement for rendered services. electronic health records (EHRs) are designed to enable providers to document patient health information and share it with other providers and systems. Many facilities rely on medical transcription services to ensure timely, accurate and comprehensive information in EHRs.

Every medical specialty has specific documentation requirements. Like other specialists, nephrologists have to manage their documentation tasks and deal with time constraints and patient compliance issues while treating people with serious medical conditions. Knowledge of nephrology documentation requirements is crucial to:

  • Communicate with other providers
  • Avoid over reporting and to document only necessary findings
  • Focus on the key elements that supporting medical decision making
  • Submit accurate claims and receive appropriate reimbursement
  • Ensure overall efficiency

Physicians should document each patient encounter completely, accurately, and in a timely manner to meet ongoing patient needs. The documentation should fully describe key clinical and diagnostic findings supporting assessment and extent of services rendered to support coding and billing.

Nephrology Documentation Requirements

All rendered services that are documented must be appropriate and medically necessary. Billing for a medical service is based on what is included in the medical documentation. Here are the basics of nephrology documentation summarized from a paper published in the Journal of Clinical & Experimental Nephrology:

In the nephrology specialty, the location of services comprises outpatient (office) and inpatient (hospital). Types of services provided include Initial Evaluation, Consultation, and Subsequent Evaluation.  Different levels of service exist within each type of evaluation due to patients’ heterogeneity and the complexities of presenting medical problem.

  • Document assessment based on discussion with patients. If final diagnosis is not reached, use terms such as “likely diagnosis” or “probable diagnosis”.
  • Briefly document the patient’s understanding of possible outcomes as well as agreement with planned treatment.
  • Follow medical documentation guidelines specific to the nephrology subspecialty, which includes the following:
    • Justify the medical service provided during medical encounter. Document only the service that was actually performed based on the necessity and appropriateness for the patient.
    • Due to patients’ heterogeneity and the complexities of the presenting medical problem, each type of evaluation will have a different level of service.
    • To qualify for billing, documentation to meet E/M requirements should include 3 key sections – History, Physical examination, and Medical Decision Making
    • History section consists of 4 parts: (1) chief complaint (CC) or reason for the visit (RFV), 2) history of present illness (HPI), (3) past medical, surgical, and social history (PFSH), and (4) review of systems (ROS).
    • As more documentation is required than ever before, nephrologists should be aware of the documentation requirements for HPI. Comprehensive HPI has 8 elements: location, severity, quality, duration, timing, context, modifying factors, and associated signs and symptoms. Other things that may be included are: quality, any modifying factors, any associated symptoms and signs, and context of the CC.
    • ROS should provide comprehensive information about the patient’s symptoms and cover 14 body systems (constitutional, eyes, ear/ nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (skin/breast), neurologic, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic).
    • PFSH: Past Medical, Family, and Social History consists of Past History, Family History (pertinent to the presenting problem), and Social History. Each area can have multiple items, for e.g., past history can include previous illnesses, surgical history, current medications, or social history can include smoking or alcohol consumption, marital status, occupation, etc. To meet E/M requirements for comprehensive PFSH, only one item from each PFSH area is required.

 

  • Evaluation of a dialysis patient can take place in the dialysis facility or the physician’s office. According to the rsearchers, documentation of the initial monthly dialysis visit should be comprehensive and include the following:
    • diet and nutrition
    • whether the current mode of dialysis is appropriate
    • assessment of dialysis access
    • preliminary assessment of candidacy for transplantation
    • assessment of dialysis prescription and dialysis adequacy
    • assessment and treatment of anemia
    • assessment and treatment of chronic kidney disease mineral and bone disorder (CKD-MBD)
    • evaluation of dialysis related complications such as neuropathy and arthropathy
    • assessment of volume status
    • assessment of blood pressure control

Though subsequent dialysis visits are termed “limited”, they also should include a brief assessment of one or more of the areas in the comprehensive assessment list.

Additional key nephrology documentation tips from www.providence.org:

  • Principal Diagnoses: Principal Diagnoses is the condition(s) which is present on admission (POA), requiring admission and treatment. It is important to confirm any condition that has been resolved. The underlying etiology should be clarified where possible.
  • Secondary Diagnoses (CCs/MCCs): Include all diagnoses which are treated and/or monitored. CCs/MCCs should be identified as “present on admission” if appropriate. Subspecialty/surgical consults can be used when needed to improve specificity of all diagnoses. A diagnosis can be documented whenever something is done on the patient (e.g., Dialysis catheter placement due to renal failure).
  • Document noncompliance with dialysis.
  • When document chronic kidney disease, identify the stage.
  • For kidney transplants, identify both chronic kidney disease (CKD) and acute
  • renal failure. Specifically, document “transplant rejection” if present, even if presumed.

How Outsourcing Medical Transcription can Help

Medical documentation accuracy depends on its quality and not the quantity of information that is recorded. As physicians focus on treating chronic kidney disease and other conditions, nephrology transcription services are a practical way to ensure quality EHR documentation. Leading medical transcription services companies have transcriptionists who are knowledgeable about specialty-specific terminology, jargon, procedures, and more. Experts can ensure error-free nephrology documentation to support patient care and optimize medical billing and coding for maximum reimbursement.

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