How EHRs Can Improve Care Coordination

04-August-2022 MTS TEAM EHR Transcription

EHRs

Electronic health records are designed to support safe, efficient and high-quality medical care. Outsourcing medical transcription promotes accurate and complete documentation in the patient record. However, proper care coordination is essential to improve the care experience for providers and patients.

According to the Agency for Healthcare Research and Quality Care (AHRQ), “coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care”. Patients and their families are also participants in this endeavor. Organizing care involves managing personnel and other resources needed to perform all required patient care activities and this typically involves exchange of information among participants responsible for various facets of care.

Care coordination implies that providers should be aware about the patient’s needs and preferences in advance and convey this information at the right time to the right people, so that it is used to provide safe, appropriate, and effective patient care. EHRs have great potential to improve care coordination.

Why Care Coordination is Crucial

Ensuring that the health care system can coordinate patient care effectively is important for the following reasons:

Existing health care systems are often fragmented, and primary care sites and specialty sites have different processes.
Patients are unsure about how to navigate care, including referral to a specialist, appointment scheduling, and what to do after the specialist consultation.
Specialists are often not informed about the clear reasons for the referral or provided adequate information on tests that have been completed. Primary care physicians are often not informed about what happened in a referral visit.
Care is not as efficient as it should be as referral staff deal with many different processes and missing information.

However, although it is an important goal for the American health care system, the AHRQ points out that there are certain obstacles that must be overcome for well-designed, targeted care coordination. The EHR can play an important role here as it consolidates and organizes patient health information and reduces fragmentation of care by ensuring that all physicians treating the patient have access to this data in real-time.

How EHRs Support Coordination of Care and Improve Patient Outcomes

Better availability of information for specialists: Improved communication can improve patient care delivery for primary and specialty care providers. EHRs can ensure that every provider shares the same, up-to-date information about a patient. This is especially important for patients that are:
- being treated by multiple specialists
- receiving emergency medical services
- making care transitions
Availability of accurate patient information can reduce medical errors and unnecessary tests. It can also help a specialist get information about a pertinent condition being treated by another specialist.

Well-informed clinical decision-making in emergency settings: Providers of emergency medical services (EMS) understand the value of coordinated care and appropriate decision making. Integrating patient health data into EMS provider workflows and sharing prehospital data with other EMS and inpatient hospital providers can help providers make fast clinical decisions, reducing risk of adverse drug reactions, hospital readmissions, and threats to patient safety. It can help paramedics act fast and stabilize patients till their hand-off to the hospital ED.

The Search, Alert, File, and Reconcile (SAFR) model developed by the Office of the National Coordinator for Health Information (ONC) promotes improved clinical decision making in emergency situations (www.ehrintelligence.com). It allows for health information exchange (HIE) between EMS and hospital emergency department (ED) personnel. With a strong HIE connection, EMS personnel can access demographic, allergy, and recent hospitalization information in patient EHRs that could be crucial at the point of care, and also communicate the patient’s current medical information to all medical providers. This can improve transitions of care and care coordination.

Improves care outcomes in Long-Term and Post-Acute Care (LTPAC): According to the office of the National Coordinator for Health Information Technology, an estimated 70 percent of Americans turning 65 years old will expect to need long-term care services at some point in their lives, many of them also requiring post-acute care. LTPAC facilities need access to timely, complete and accurate patient records to take fully informed care decisions that improve patient safety, and also avoid preventable hospital readmissions, ED visits, length of stay, and other adverse events. Integrating patient EHRs and medication histories into LTPAC facilities offers many benefits:
- Improves care coordination by ensuring that providers have data regarding adverse drug reactions and associated readmissions
- Reduces/prevents the negative effects of medication errors for patients
- Helps reduce the risk of costly hospital readmissions
EHR Intelligence reported that health IT company Surescripts expanded its real-time Medication History for Reconciliation (MHR) service to cover LTPAC facilities to support optimizing patient health outcomes and patient safety.,

Increases patients’ ability to participate in care coordination: EHRs can also support patients’ engagement in their care. When providers and patients share access to digital medical records, it can promote joint decision making, which is particularly important for managing chronic conditions such as asthma, diabetes, and obesity. When patients can access their own medical records, they would become more conscious about own care. This can help them better understand their providers’ instructions and help them make informed decisions. However, educating patients on how to use health data and patient portals is important to empower patients in care coordination, especially patients with low digital health literacy.

The benefits of leveraging an EHR across the continuum of care, according to the Office of Health Information Technology (IT) and the National Learning Consortium, allows for:

Better integration among providers by improved information sharing.
Viewable and current medication and allergy lists.
Order entry at point of care or off-site.
Standardization of data, order sets, and care plans helping to implement common treatment of patients using evidence-based medicine.
Access to experts for rural health care providers by sharing best practices and allowing for specialized care through telemedicine.
Population management trended data and treatment and outcome studies.
More convenient, faster, and simpler disease management.

Regardless of the setting, to improve care coordination utilizing EHRs, healthcare professionals need access to timely and precise patient information. Medical transcription companies play an important role in ensuring accurate and comprehensive electronically-stored health information in digital format. They provide HIPAA-compliant EHR-integrated medical transcription services for the many different participants involved in coordinating care.

Strategies To Improve Electronic Health Records Documentation

01-August-2022 Julie Clements EHR Transcription

Electronic Health Records

Almost a decade has passed since it became mandatory for healthcare providers to switch to electronic health records (EHRs). However, usability issues persist, and increased documentation requirements and shifting federal regulations have led to higher workload and physician burnout. Data collection and documentation using EHRs are key to quality care and patient safety, care quality, and provider accountability and efficiency. Medical transcription services are a widely accepted strategy to reduce unproductive keyboard time. Experts have put forward various other strategies to help medical practices optimize EHR use and documentation, enable providers to find the information they need quickly, increase face-to-face time with patients, enhance patient safety, and decrease provider burden.

According to the Healthcare Information Management Systems Society (HIMSS), EHR usability is “The effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment. In essence, a system with good usability is easy to use and effective. It is intuitive, forgiving of mistakes and allows one to perform necessary tasks quickly, efficiently and with a minimum of mental effort.”

In a study conducted by Mayo Clinic and the American Medical Association (AMA), most providers assigned EHR usability an “F” grade. Optimizing EHR documentation is closely associated with maintaining and improving EHR usability.

Here are Four Top Ways to Improve EHR Usability and Documentation

Optimize the EHR interface: This involves tweaking the EHR system to meet the practice’s individual needs and improve clinical productivity and efficiency. EHRs need to be easy to navigate and ensure usability and interface features that the clinician needs. On the other hand, an EHR with a cluttered interface can have disastrous consequences. Among other things, it can affect medication prescription and lead to repetitious or unnecessary test ordering. A well-designed and simple-to-use interface with aids to alert the physician will significantly improve patient care and provider satisfaction and productivity. A user-friendly, high-performing EHR interface will record, maintain and manage data on a patient, so that caregivers have the right information at the right time to make the best possible decisions for patients.

Conduct tests to maintain EHR usability: Keeping the EHR up-to-date is crucial for usability and good documentation. An EHR Intelligence report recommends conducting internal tests to maintain EHR usability throughout the system’s life. The report recommends that after EHR implementation, ‘summative’ testing should be completed. Such tests include expert review, performance testing, risk assessment, and usability testing.
EHR vendors use the validated system usability scale (SUS) to assess satisfaction with product ability. According to researchers, a score of 80 is above average while 68 is an average benchmark response. The vendor can use this feedback to improve EHR design. Health systems can also use the test results to improve optimization.

Provide EHR training: Several studies have highlighted the importance of training to optimize EHR use and documentation. EHR technology is continuously updated, and investing in learning for clinicians on EHR functionality can address several challenges including documentation concerns. Progress notes support medical decision-making, patient-provider communication, critical thinking, billing, and institutional coding. For patient safety and patient care, clinicians need to know how to effectively and efficiently document progress notes in the EHR. Training is crucial for this. Residents grasped the details and intricacies of EHR documentation after EHR training workshops, according a study published in the Association of American Medical Colleges’ Training can also help users better navigate the EHR interface instead of implementing a new system, according to the EHR Intelligence report.
Harness technology: Technologies such as voice recognition, digital scribes, and connected devices automate and speed up the documentation and reduce clinician time spent on EHR data entry tasks. A Medical Economics report highlighted the increasing use of EHR-integrated apps for a wide variety of functions such as scheduling, check-in and billing, clinical functions, care management and patient engagement. The article references Micky Tripathi, national coordinator for health information technology at the U.S. Department of Health and Human Services as saying that these apps are the key to unlocking more functionality from EHR systems and directly addressing physician frustration.
Medical transcription outsourcing: Quality in EHR documentation is typically measures based on elements such as completeness, accuracy, clarity, and timeliness. Outsourced medical transcription services are a reliable option to improve the quality and timeliness of medical documentation, without additional capital investment. Experienced medical transcription companies provide EHR integrated transcription for all specialties, from family practice, physical therapy and cardiology transcription to pain management, nephrology and radiology transcription services, to name a few.

Areas to Focus on to Improve EHR Use

Medical practices can address clinical burnout and improve EHR documentation by focusing on four key areas: improving patient care, boosting physician productivity, ensuring accurate reimbursements, and cutting operational expenses. Outsourcing medical transcription to a company that provides services can help practices optimize EHR documentation, enhance patient care, and reduce operational costs.

Guidelines For Physical Therapy Documentation

25-July-2022 Rajeev Rajagopal Physical Therapy Transcription

Physical Therapy

Physical therapists need accurate medical record transcriptions in order to evaluate their patients’ conditions and choose the best course of treatment. For hospitals, outpatient clinics, group practices, and individual physicians, US-based medical transcription companies provide physical therapy transcripts that are accurate, dependable, and delivered on time.

Physical Therapy Documentation and Its Importance

Every time they interact with a patient, physical therapists must gather information about the interaction and record it in their clinical file. This clinical record is composed of notes and other materials that describe the patient’s evaluation, treatment, progress, and plan. It is crucial that all information in your physical therapy documentation is clear, accurate, and full because the record may be used by other healthcare professionals, office personnel, or even in a court of law.

Having accurate physical therapist notes helps in:

Ensure continuity of care: Accurate medical records will make it simple for any new healthcare practitioner your patient works with to develop an efficient treatment plan.

Give patients the best care possible: It will be easier for your patients to obtain better care from you or another healthcare professional if you keep a record of their original condition and their path to recovery. On the other hand, incorrect notes may result in undesired or even harmful consequences.

Prevent any malpractice: In a court of law, documentation is admissible by law. Thorough and accurate medical documentation will support your claim that you met or surpassed the standard of care if you ever find yourself in a legal situation.

Proper billing: Your records will assist you in producing accurate invoices and insurance claims for your services and serve as documentation in the event that a bill is contested.

Tips to Document Physical Therapy SOAP Notes

One of the most important aspects of managing a physical therapy practice is maintaining the appropriate documentation. It is your duty as a healthcare provider to make sure that each patient’s records are organized and accurate on a professional, ethical, and legal level. It is best to use the SOAP format while drafting assessment notes. Physical therapy SOAP notes are a standardized approach for taking medical notes that can help make sure your records are accurate and simple for other professionals to interpret.

Never throw away or remove any physical therapy records or paperwork pertaining to communications you have had with a patient. It’s always best to keep it if you’re unsure. Keep in mind that all records must be kept in a location that is both safe and secure and simple to access when necessary.

Healthcare practitioners can use a variety of resources from the Centers for Medicare & Medicaid Services to make sure that their documentation and physical therapy treatment notes adhere to all applicable laws.

Every entry you make in a patient’s record should be timed, date-stamped, and signed. Identify the patient by giving their name, birthdate, and file number. Avoid superfluous industry jargon and acronyms that could lead to confusion, make sure you consecutively number all of your pages.

General Guidelines

All documentation must abide by all applicable legal and regulatory standards.

Original signatures must be included with all handwritten entries, which must be done in ink. The proper security and confidentiality measures are in place while making electronic entries.

Charting mistakes should be fixed by erasing the error with a single line, initialing the chart, and dating it. For electronic documentation, use the appropriate technique that makes it evident that a modification was made without erasing the original record.

Identification:
- On all official documents, please include the patient’s or client’s full name and, if relevant, their identification number.
- All submissions must be validated, dated, and include the provider’s complete name and the correct abbreviation, such as PT or PTA.
- Graduates and anyone waiting to receive an unrestricted license must have their documentation verified by a professional physical therapist.
- In programs for physical therapists or physical therapist assistants, documentation by students (SPT/SPTA) must also be validated by a physical therapist. When permitted by legislation, documentation by physical therapist assistant students may also have a physical therapist assistant authenticate it.

All physical therapy documentation should include the referral process that is used to begin receiving physical therapy treatments.

Also Read: Accurate Physical Therapy Records Vital for Better Profitability

A vital component of a physical therapist’s job is to record patients’ physical therapy treatments. But at the end of the day, paperwork can be a very laborious chore for a physical therapist. However, for proper claim submission, continuity of treatment, and administrative effectiveness, it must be done precisely. Therefore, physical therapists often choose to outsource medical transcription to a reliable transcription provider that provides advantages including reduced administrative costs, streamlined business procedures, and increased productivity to help you acquire a competitive edge. They also ensure HIPAA compliance to ensure safety of medical records.

How Medical Transcription Services Help Family Care Practitioners

21-July-2022 MTS TEAM Medical Transcription

Family Care Practitioners

Just like doctors in any other specialty, family care doctors spend a lot of time and money in generating accurate medical records. This is where medical transcription services become important for family care practitioners. Medical transcription companies have transcription experts that have a clear understanding of medical conditions and terminologies; they would also meet all requirements to generate accurate medical records. They offer transcription service for:

Reports of physical examinations
Accident injury reports
Immunization and allergy-related reports
Reports on the management of chronic diseases
Reports on follow-up visits
Children’s Records

Medical Transcription for Family Care Physicians

Family care covers clinical, biological, and behavioral sciences. A family doctor provides care to members of all age groups of the family with a focus on building a caring and long-lasting relationship with patients and their families. Family care doctors are constantly busy since they have a variety of health procedures to do, such as diagnosis, immunization, and screening. This results in a tonne of paperwork, reporting, findings from lab and radiological tests, and so on. In order to save time and increase production, family practitioners can work with reputable family practice medical transcription service providers.

Advantages of Family Care Medical Transcription

More Time with Patients: Primary care doctors frequently dictate patient notes that can be typed out later. Transcribing all of these recordings and entering them into the database can be very time- and labor-intensive. However, if you outsource this to a medical transcription providers, PCPs will be able to spend more time seeing patients and less time keeping track of patient notes and updating EHR records.
Maintaining Revenues: Your family care practice may become more productive if you outsource the transcription of EHRs. One benefit is that you will be able to see more patients. This allows your staffs to spend more time escorting patients to exam rooms, handling paperwork, answering phones, and greeting patients. This results in a more effective medical practice, better patient care and services which helps to increase revenue. If your family practise is smaller and has a narrower profit margin, this may be even more crucial.
Minimizing the Chances of EHR Errors: EHR text fields should be filled accurately. All patient data should be entered into the right EHR text field. To prevent problems that can have an impact on insurance payments, medications, and other areas of treatment and care, must also be correctly entered. EHR database specifications are a specialty of EHR transcriptionists. The risk of any mistakes and oversights can be reduced by the precision and meticulousness of transcriptionists.
Provides Meaningful Patient Notes: It is common for some family care practices to reduce typing requirements, particularly for EHR entries, by reverting to generic drop-down choices. While basic patient information can be uploaded into the system in this manner, it is not customized. You can take more time to dictate and generate more relevant and detailed patient notes if you know you’ll be working with a skilled and experienced medical transcriptionist.
Improving Office Costs: If your family practice is already operating on a tight budget, EHR-related transcribing can help reduce overhead expenses. For instance, you won’t need to employ additional people to perform transcription job full-time. The alternative is to outsource these services and only pay for what you actually require. Additionally, you won’t need to spend money on transcribing equipment, which can be costly and frequently necessitates additional costs for software updates. Additionally, you won’t have to bother about educating your current personnel on the fundamentals of electronic health records and transcribing.

Every day, family care physicians deal with a large number of patients and associated tasks, which also entails a large number of obligations. PCPs are required to be aware of significant laws and regulations in addition to attending to the particular needs of each patient. However, PCPs get very little time for documentation chores due to their hectic work schedules, and dealing with patients of various ages. This is why they resort to reliable medical transcription services. It helps with accurate medical record keeping that provides family care doctors the information they need to efficiently administer the proper care to their patients. Other benefits include:

Quality check: They have three-tier system that ensures quality check and ensures that the medical terminologies are transcribed accurately.
Minimal Error Rate: To ensure error-free transcripts, all transcribing work is carried out by qualified professionals rather than by any speech recognition algorithms.
HIPAA Compliance: The team of transcriptionists undergoes regular HIPAA training and they ensure security and confidentiality.
Single point of contact: These services offers one professional who act as the single point of contact and is responsible for keeping you updated about the project or any issues.
Experienced team: These services have professional transcriptionists and proof-readers who ensure accurate medical records.

How To Write Good DAP Notes [INFOGRAPHIC]

18-July-2022 Julie Clements Infographics

Maintaining proper mental health progress records is important for practices to provide patients with the care they need. EHR integrated mental health transcription services offer many benefits such as better collaboration among providers, improved medication management and crisis management, health information privacy and security, and much more.

The two common mental health documentation methods are SOAP (Subjective, Operative, Assessment and Plan) and DAP (Data, Assessment, and Plan). While the main purpose of SOAP notes is to help providers monitor patients with multiple conditions, the DAP note aims to helping mental health professionals document and track the patient’s progress in an organized and efficient manner. DAP note merges the Subjective and Objective elements under the Data section.

Check out the infographic below

DAP Notes

Read our blog on DAP vs SOAP Therapy Notes? What Are The Differences?

Can Patient Access To EHR Clinical Notes Improve Medication Adherence

14-July-2022 Rajeev Rajagopal EHR Transcription

EHR Clinical Notes

Medication adherence is an important goal of patient care. Nonadherence to medications is associated with adverse outcomes and higher health care costs. Outsourcing medical transcription can ensure accurate medication lists in electronic health records (EHRs) about the drugs the patient is prescribed and their dosages. However, medications will work only if the patient takes them.

Medication nonadherence is when patients skip their doses or fail to take them at the prescribed times. This can reduce and can even completely destroy the effectiveness of the prescription. Reports say that medication nonadherence as the US population ages and patients take more medications to treat multiple chronic conditions. Physicians and healthcare professionals should strive to implement strategies to improve patient medication compliance.

According to a study published in The Journal of the American Geriatrics Society in August 2021, patient access to EHR clinical notes can improve medication adherence, especially for patients with chronic conditions. Previous research has shown that older patients are less likely to be offered information related to patient portals. However, this study suggests that these patients and their care partners could benefit significantly by accessing these notes.

Medication Nonadherence – Reasons and Consequences

Medication nonadherence costs us a half-trillion dollars per year and 16% of U.S. healthcare spending goes toward unnecessary costs associated with patients not taking their medications, according to a www.healthleadersmedia.com report. According to the World Health Organization (WHO) the problem costs over $100 billion annually while accounting for approximately 125,000 deaths each year. The WHO notes that improved medication adherence can have a more direct impact on patient outcomes than improvements to the specific treatments they are undertaking.

What are the factors contributing to medical non-adherence? The WHO has categorized the reasons for medication nonadherence in 5 broad groups: patient, condition, therapy, socioeconomic, and health system–related factors. The American Medical Association elaborates on these reasons as to why patients don’t take their prescribed medications:

Fear of potential side effects and side effects experienced with previous medications.
High costs of medications.
Not understanding the importance of taking the medicine.
Multiple prescriptions for various conditions.
Not experiencing symptoms can cause patients to discontinue a prescribed medication.
Mistrust or interpreting the physician’s motives for prescribing a drug as commercial.
Concerns about becoming dependent on the medication.

What Are The Consequences Of Medication Nonadherence?

One main effect is increase in symptoms, complications, and comorbid diseases. These issues will lead to worsening of the condition and need for prolonged hospitalization. The most severe consequences of non-adherence are disease progression, adverse effects, and death. Medication non-adherence leads to higher health care costs and unnecessary healthcare spending amounting to billions of dollars each year.

The AMA stresses the importance of understanding why patients don’t take their medications. This will help physicians and other health professionals to identify and improve patients’ adherence to their medications. According to recent research, access to EHR clinical notes can improve medication adherence in patients with multiple chronic conditions.

Study Links Medication Compliance to Patient Access to EHR Notes

Studies have suggested that when patients read their visit notes, it can improve medication adherence. The study published in The Journal of the American Geriatrics Society is based on a cross-sectional country-wide survey of patient portal users over age 65.

The study found that EHR access by older patients with chronic conditions may support greater patient engagement and medication adherence. Here are key points that emerged from the study as summarized from an article published by EHR Intelligence:

Older patients value access to their personal health information, including clinical notes.
In the year before the survey, all the participants had read at least one clinical note, and most had read two or more clinical notes.
Patients with two or more chronic conditions were more likely to report that EHR clinical notes access helped them stay engaged in their care, remember their care plan, and experience better control over their medications, which led to greater medication adherence.
Very few patients reported confusion about their health or medications due to reading their EHR clinical notes.

In this survey, respondents had education levels beyond high school and had fairly high levels of digital literacy. However, the researchers noted that several previous surveys suggest that, compared to other patients, reading clinical notes increased engagement and trust in nonwhite, less educated, older patients, or those whose preferred language is not English.

The researchers recommend that health systems should aim to ensure that all older patients have access to appropriate health information in a format that is personalized to meet their needs. This will improve patient engagement for people of all literacy levels.

“Healthcare organizations should work to maximize patient’s engagement with their health information both through the patient portal and through other methods to ensure that patients and the healthcare systems reap the full benefit of the increased transparency of medical records,” the researchers wrote.

Medical Transcription Services for Accurate and Timely EHR Clinical Notes

Accurate and timely charting is crucial when it comes to optimal utilization of EHRs. In fields like cardiology, for instance, the prescription of indicated cardiovascular medication to patients has improved vastly, and the next step is to improve adherence to prescribed medication, according to an article published by the American Heart Association (AHA). Providers working to implement interventions to enhance medication adherence can benefit greatly from cardiology transcription services. A competent medical transcription service organization can help physicians maintain precise, concise and clear clinical notes with an up-to-date medication list. With the right support, healthcare providers can optimize medication compliance that minimizes adverse outcomes, reduces costs, and eventually lead to improved patient outcomes.

Outpatient Rehabilitation Therapy Documentation Requirements

11-July-2022 MTS TEAM Physical Therapy Transcription

Outpatient Rehabilitation Therapy

Outpatient rehabilitation therapy comprises physical therapy, occupational therapy, speech and language therapy services. Rehabilitation helps people get back, maintain, or improve abilities needed for daily living. Physical therapists, for instance, identify, diagnose, and treat mobility issues and help people of all ages restore their functional abilities, and avoid the need for surgery. Rehabilitation therapy can reduce the symptoms of many chronic diseases and conditions, and help people get their abilities back after surgery or injuries and trauma. While providing interventions to meet the specific needs of each patient, therapists need to maintain proper documentation to justify services and ensure appropriate reimbursement from Medicare and private insurance plans. Since many providers find it challenging to document effectively while providing care, medical transcription outsourcing has emerged as a reliable option for consistently and accurately reporting rehab services.

Importance of Effective Documentation for Therapy Services

Consistent and accurate information in the medical record and the documentation accompanying claims is critical to:

Show that the therapy services were medically necessary.
Justify the appropriate type of services, frequency, intensity, and duration for the individual needs of the patient.
Ensure compliance with the exceptions process – there is a targeted medical review threshold for occupational therapy and for speech-language pathology and physical therapy combined. The documentation should support the provision of services above the cap.
comply with all legal/regulatory requirements applicable to payer requirements for claims
get paid for the covered therapy services

Outpatient Rehabilitation Therapy – What Documentation Should Include

Documentation should:

Establish the need for therapy services.
Establish the factors that influence the patient’s condition, especially the factors that influence the clinician’s decision to provide more services than are typical for the individual’s condition.
Provide objective measurements to establish that that the patient is making progress toward goals. As plains (no progress) or valleys (regression) can happen during treatment, CMS recommends that the documentation notes the reasons for lack of progress and the justification for continued treatment if treatment continues after plains and valleys.

Types of Documentation for Therapy Services

Written Plan of Care (POC): Therapy services should be specifically associated with a written treatment plan or POC, including an evaluation. It is necessary to establish the POC before the therapy begins. In a Comprehensive Outpatient Rehabilitation Facility (CORF), only the physician can establish the POC. The POC should include the following information:
- Diagnoses
- Long term treatment goals; and
- Type, (PT, OT or SLP) amount, duration, and frequency of therapy services)
- The signature and professional identity of the person who established the POC and the date
- The physician’s or NPP’s written or verbal approval
- Any significant long-term goals

The evaluation should include a diagnosis and description of the specific problem(s) to be evaluated and/or treated. The medical record documentation should identify objective, measurable patient physical function including functional assessment and measurable progress towards identified goals for functioning in the home environment at the completion of the therapy episode of care. The referral/order of a physician/NPP is essential to show that the evaluation is needed and the patient is under the care of a physician.

If it is difficult to document the POC while providing care, PTs can develop a dictated POC and get it converted into text using a physical therapy transcription service.

Progress Reports: Progress notes need to establish the medical necessity of the therapy services. ASHA states that:
- The clinician must complete a progress report at least once every 10 treatment days or at least once during each certification interval, whichever is less.
- The first reporting period begins on the first day of the episode of treatment regardless of the services provided – evaluation, re-evaluation, or treatment.
- The progress report should contain an assessment of improvement or lack of it for each goal; plans for continuing treatment, additional evaluation results, and/or treatment plan modifications; changes to long- or short-term goals, discharge, or an updated plan of care sent to the physician/NPP for approval of continuation of treatment.
- The notes could include objective evidence (patient assessment instruments, tests, outcome measurement tools) that the patient’s condition has the potential to improve in a reasonable and generally predictable period of time or is improving in response to therapy. Though not required, the use of these tools will support the need for the therapy.

Treatment Notes: Treatment notes should provide a record of all encounters and skilled intervention. Every therapy service provided on each treatment day should be documented and must include the following:
- The name of the treatment, intervention of activity provided in the encounter note.
- Total treatment time.
- Any changes in treatment with justification for the same.
- Upgrades to the patient’s activity that show skilled treatment. Including objective measurement to support this can be helpful.
- If there is no improvement, information on any setbacks, illness, new condition, or social circumstances that are hindering progress and reasons why attaining progress is still possible.

Discharge Note: The discharge note written by the clinician should include all treatment provided since the last progress report to the date of discharge. It should indicate that the notes were reviewed by therapist and that the therapist agrees to the discharge.

Physical and occupational therapy services provided in an outpatient setting can take place in the office, hospital, home, and other settings. To show that the standards of care were met and receive reimbursement for their services, providers should submit error-free claims with comprehensive and appropriate documentation to meet payer rules and federal policies. Partnering with a medical transcription outsourcing company can ensure clear and complete outpatient therapy records to:

Provide quality patient care
Ensure continuity of care
Correct coding and billing
Avoid malpractice
Maintain complete HIPAA-compliance

US based medical transcription companies provide timely and focused EHR documentation solutions for all specialties including physical therapy, occupational therapy, and more.

10 Strategies To Prevent Medication Errors

07-July-2022 Julie Clements Medical Transcription

Medication Errors

All healthcare professionals need to maintain consistent records of their activities to ensure proper tracking of activity related to the patient. Medical transcription outsourcing is a reliable strategy to ensure accurate records that promote proper care delivery by all providers caring for the patient and protect healthcare organizations in the event of litigation. Accurate records can play a key role in preventing errors in administration of medicines.

In a busy, fast-paced healthcare setup, medication errors can occur due to many reasons and at any stage of the medication process. The different types of medication errors are:

Prescribing errors
Administration errors
Failure to prescribe, administer, or dispense a medication
Not following a medication’s dispensing/prescribing rules
Administration of a medication too late or too early
A patient being given a medicine not prescribed for them
Improper use of a medication
Wrong dose prescription/preparation
Not paying attention to the patient’s medical conditions or potential drug interactions

Medication errors can have serious consequences such as prolonged hospitalization, need for additional medication interventions, and severe patient injury or death.

The main reasons for medication errors are insufficient pharmacologic knowledge, miscalculations, distractions, increased workloads, and fatigue, according to an article published in Nursing. Medication errors are highly preventable. Here are 10 effective strategies to prevent or reduce the risk of medication errors.

Follow the 5 rights: In 2018, Patient Safety Network estimated that there is about an 8%-25% median medication error rate during medication administration. Nurses can prevent medication errors by following certain rights of medication administration: right drug, right patient, right dose, right time, right route of medication administration. Other rights include: right reason, education, documentation, right to refusal and expiration date.
Proper drug calculation: Proper medication calculation is an important skill for nurses. Mathematical skills are required to make accurate drug calculations and administer medications safely and minimize errors.
Medication reconciliation during patient transfer: When a patient is moved from one facility to another or to another unit in the same facility, all medication should be reviewed against transfer instructions. Each medication should be verified to ensure correct patient, dosage, route, and time of administration.
Continuing education: Nurses should stay updated about new drugs and their safe use, including patient monitoring, patient teaching, and documentation. Maintaining ongoing medication competency is prevent errors when administering new medicines.
Double checking: Double checking is defined as a procedure that requires two qualified health professionals checking the medication before administering it to the patient. A medical transcription service provider documents all physician orders on each patient’s treatment administration record. Nurses should independently verify each medication on the patient’s order to ensure it is noted and transcribed correctly. Chart flags can also help, especially for high alert medications.
Verbal orders – know the rules: Electronic prescriber order entry and prescribing have significantly reduced errors resulting from unclear handwritten and verbal orders. However, reports say that verbal orders still persist. Verbal orders have the potential to be misinterpreted, misheard, or transcribed incorrectly. These issues make them error prone when the prescriber and the person receiving the order have different accents, dialects, and drug name pronunciations.

However, the American Medical Association (AMA) has clarified that there are no federal regulatory prohibitions on the use of verbal orders. According to CMS, “verbal orders must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient. That practitioner must be acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations”. The AMA recommends the use of repeat-back of the order by the documentation assistant, especially for new medication orders.

Indication alerts: High-alert medications are those that carry a higher risk of causing significant patient harm when they are used in error. The most serious errors reported due to similar names are associated with high alert medications. The Institute for Safe Medication Practices (ISMP) recommends the following strategies to reduce risk of errors linked to high alert drugs:
- Standardizing medication ordering, storage, preparation, and administration
- Improved access to information about these drugs
- Limiting access to high-alert medications
- Using auxiliary labels and automated alerts
- Employing redundancies
Minimize distractions: Eliminating distractions during medication preparation can reduce risk of medication errors. This means implementing the ‘sterile cockpitrule’ in the medical setting. Even when conversations occur and are necessary between nurses and patients, nonessential activities or conversations can be prevented with a ‘quiet zone’ sign in the medication preparation area (journals.lww.com).
Safe storage of medications: As heat, air, light, and moisture can damage medicines, there should be proper measures in place to ensure their safe storage. Certain medications need to be kept refrigerated to maintain efficacy, while others may need to be stored at room temperature. When multidose vials are used they should be labeled to prevent usage after their expiration date.
Patient education: Empowering patients, families, and caregivers can prevent medical errors. They should be educated about medications’ therapeutic effects, potential adverse reactions, and desired outcomes. Nurses should review medications and their possible reactions with patients and educate them on how to stay safe. This is especially important when patients manage their medication regimens at home.

When used correctly, technology can help to decrease medication-dosing errors. For instance, bar code-assisted medication administration (BCMA) requires the nurse administering the medication at the bedside to scan the patient’s identification bracelet and the unit dose of the medication. It there is a mismatch of patient identity or of the name, dose, or route of administration of the medication, the system will alert the nurse about it. Electronic health records (EHRs) can also reduce medication errors by sending alerts about food/drug and drug interactions and identifying potential drug side effects and/or adverse reactions.

Providers must keep accurate records of medication administration to prevent errors in dosing. Nurses should document the dose only after the medication is given. A medical transcription company can ensure accurate EHR documentation of patients’ medication administration as well as allergies.

This can go a long way in helping to prevent medication administration errors. However, transcribed records of medication administration in the patient chart should be used in accordance with the instructions of the prescriber ((www.sps.nhs.uk/articles). The transcribed information should not be used in place of prescriptions, to add new medicines, to supply or dispense drugs or to change original prescriptions unless it is counter-signed and validated by the prescriber.

Reliable Ways To Evaluate Medical Transcription Productivity [INFOGRAPHIC]

04-July-2022 Julie Clements Infographics

All businesses need to track employee productivity and time taken to complete a specific job. With the continued evolution of clinical documentation, technologies, and reasonable expectations of customers and service providers, measuring staff productivity and overall performance has become very important for medical transcription service providers. In professional medical transcription service companies, managers will clearly define and communicate productivity expectations and goals to the team, which is important to set realistic, reasonable tasks and deadlines to meet client goals. Tracking progress helps gain insight on how everyone can improve their productivity levels, which in turn, will contribute to improved workflow throughout the organization.

Check out the infographic below

Medical Transcription Productivity

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What Are The Benefits Of Adopting A Specialty EHR?

30-June-2022 Rajeev Rajagopal EHR Transcription

EHR

Electronic health records (EHRs) have vastly improved patient care coordination and delivery. Every medical practice aims to achieve accurate and thorough EHR documentation. Medical transcription outsourcing plays a significant role in making the process of clinical documentation efficient and freeing up providers to focus on the patient. With continual technology upgrades, practices can now implement a medical specialty-specific EHR. From cardiology, neurology, pediatrics, dermatology, and behavioral health, EHR requirements vary across specialties. With customized templates and a host of other features, specialty specific EHRs can support workflows to meet the specific needs of medical specialists. Let’s take a look at the benefits of a specialty-specific EHR.

Special features to cater to the niche: A specialty-specific EHR is all-in-one solution that enhances the efficiency of the practice and allows the provider to manage all aspects of patient care. For example, a 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 EHRs are flexible, operate efficiently in all conditions, and help providers in creating a comprehensive centralized patient record.

Improves 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, and 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 with neurologic diseases. 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 streamlined to meet a particular specialty’s needs. It is designed 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 HER delivered EEG reports on the same day.
Accurate documentation: Proper and detailed documentation of the clinical examination is crucial to accurately diagnosing and following progression of complex conditions such as 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 companies 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. By integrating with the practice management software, a specialty-specific EHR can decrease no-shows, and improve patient satisfaction and engagement, scheduling, billing, payment processing, and communication.
Meets specialty-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, going a long way to improve the administrative aspects of the practice and bottom line.

Choosing a Specialty EHR – Key Considerations

The best specialty EHRs include the advanced features described above. Keeping the following considerations in mind can help you choose a specialty EHR:

Flexibility to meet your specialty’s needs
Scalability to accommodate all the providers in your specialty 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.

View our infographic on Major Benefits Of Adopting A Specialty EHR [INFOGRAPHIC]