Why Medical Transcription Is a Better Choice than Voice Recognition Software

27-June-2022 MTS TEAM Medical Transcription Company

Medical Transcription Is a Better Choice than Voice Recognition Software

Since the introduction of EHRs, healthcare providers are having a hard time juggling EHR documentation and patient care, and this has led to physician’s burnout. Outsourced medical transcription services are a practical solution to this problem. It helps generate accurate medical records, promotes quality patient care, ensures proper reimbursement, and maximizes overall practice efficiency.

Voice Recognition Software Vs Medical Transcription Services

Some healthcare professionals use voice recognition software or artificial intelligence based software for medical documentation whereas some rely on medical transcription services. During the consultation, physicians have to type everything on the EHR system. The average physician’s typing speed is only 30 words per minute which is why they choose to dictate their notes.

Physicians can speak into a recording device, which then sends the information to speech recognition software. The software converts the physician’s dictation into written text, which may subsequently be modified and reviewed. There is a technical distinction between voice recognition and speech recognition: voice recognition recognizes the person speaking, whereas speech recognition recognizes the words spoken. The advantages of voice recognition software are:

Simple physiological disorders, such as heartburn, can be easily documented using basic question lists or algorithms in EHR, but more complicated conditions frequently include psychosocial symptoms that are just as essential. In such cases, being able to communicate directly with patients about their experiences generates more detailed data and problem lists.
Voice recognition software allows clinicians to think aloud, which can results in unique insights that might otherwise go unnoticed if data was entered manually. It all boils down to time for many providers. Instead of thinking in terms of manual data entry, they can allow their natural thought process dictate the notes, which is typically faster.
When the patient can hear what the physician is writing in the record, they are more likely to believe that he or she is paying attention to them and that they are receiving better treatment. Patient satisfaction has an impact on treatment adherence. Patients are more inclined to disclose critical information that can enhance their outcomes if they believe what they’re saying is more thoroughly captured in their records.

Another method of converting physician’s dictation into medical records is with the help of medical transcription services. Apart from patient care, healthcare providers have several other responsibilities to accomplish. As a result, boosting overall efficiency is critical to a healthcare organization’s performance. However, this is sometimes difficult to achieve, given how much work needs to be done every day. Using a medical transcription service provider not only ensures a dependable and accurate method to streamline medical documentation, but also frees up staff time to focus on other critical needs or activities throughout the day. Imagine how much better patient care would be if a physician didn’t have to spend numerous hours each day transcribing notes. It allows doctors to record patient data at their leisure, which may then be transmitted to a service that will transcribe it while the physician spends time with the patient. Instead of staring at a computer screen documenting the appointment, the physicians can look at the patient and talk to them without any interference.

The Key Advantages of Medical Transcription Services

The physician must evaluate the documentation created by speech recognition software. It is easy to let mistakes slip through the gaps when editing one’s own work, but physicians can’t afford to provide medical records with even a few typos. When it comes to proofing essential documents, nothing matches the human touch which a medical transcription company can provide. Improved accuracy reduces the likelihood of malpractice litigation and enhances audit protection, both of which can provide greater peace of mind to practitioners.
Achieving interoperability is one of the most important goals in healthcare. It refers to the secure integration of and access to electronic health data so it can be used to optimize health outcomes. Due to the extensive manual setup involved, speech recognition software usually has limited ability to connect with EHRs. Medical transcription companies, on the other hand, are well-known for their ability to work with a variety of EHRs. The most reliable transcription services integrate directly with EHRs, populating charts with the necessary data as soon as the transcription is finished. Completed transcripts will be transferred to your practice’s EHR in a seamless and HIPAA-compliant manner, reducing stress and saving time.
The Health Insurance Portability and Accountability Act (HIPAA) is well-known among physicians and medical professionals, but with so many voice recognition software possibilities, not everyone recognizes that these programs aren’t necessarily HIPAA-compliant. Recognizing the critical necessity of data security, reputable medical transcription vendors require all workers to complete extensive training on HIPAA and security best practices.

Voice recognition may seem like an easy process at a first look, but it can lead to errors in medical records which will affect patient care, and can even prove fatal. The John Hopkins University School of Medicine notes that one-third of all deaths throughout the country in the United States are caused by a medical error. Medical errors such as incorrect drug prescriptions and diagnoses, are much more likely to occur with voice recognition software.

Where Does Technology Fail?

The lack of contextual awareness is the most obvious difficulty with voice recognition and AI-powered apps. They can only hear and transcribe words one at a time, with no context to influence which term they choose to write. As a result, uncommon, lengthy vocabulary may be misidentified and transcribed incorrectly. Human medical transcriptionists, on the other hand, have a broad awareness of anatomy, medications, diseases, and testing, as well as a fundamental command of the English language, which guides their sentence structure and word selections. As a result, the EHR documentation they help create is accurate and understandable. Medical transcriptionists can also fix error in AI-generated text.

A Blended Approach: Medical Transcription and EHR

A combined strategy that includes both medical transcription and structured EHR templates could help to overcome all of these issues. Physicians can dictate patient information into a recording device and these audio recordings are encrypted and transferred to an outsourcing company offering medical transcription services. Such companies have experienced transcriptionists who will convert them into accurate text that can be integrated into the EHR. The key benefit of this hybrid method is that it will help practices meet the government’s EHR mandate while ensuring accurate clinical documentation. It will also allow physicians to spend more time with their patients and focus on providing better care.

How Long Do Hospitals Keep Medical Records?

23-June-2022 Julie Clements Medical Transcription

Medical Records

A medical record contains information about the patient that is important for future and current healthcare providers to deliver the necessary care. Most providers rely on outsourced medical transcription services to maintain accurate and timely records of a patient’s identification information, medical history, medication history, family medical history, treatment history, and medical directives.

Good medical records are important for patients and physicians. A medical record contains information about a patient’s health and medical history. The level of detail and type of information will depend on the patient’s condition and the care they require. Insurance companies often request medical documentation during claim evaluation to determine reimbursement. Patients can request a copy of their medical record at any time.

So, for how long do hospitals need to retain medical records?

Factors Governing the Timeline for Medical Record Retention

There are multiple options for storage of medical records such as scanning to optical disk, use of microfilm or microfiche, and off-site storage. A record retention schedule is essential due to storage space restrictions, and the need to manage large volumes of information and facilitate easy retrieval.

Medical transcription companies help providers create medical records from physician dictation. The four steps in medical records management are: creation, utilization, maintenance and destruction. So the process begins when information is created and ends when the records are destroyed. While creating and using medical records is a fairly straightforward process, issues may arise when it comes to maintaining information. According to AHIMA, healthcare organizations need to manage record retention schedules to ensure:

Availability of patient health information to meet the needs of continued patient care, legal requirements, research, education, and other legitimate organizational requirements
Guidelines on what information is kept, the time period for which it is kept, and the storage medium (e.g., paper, microfilm, optical disk, magnetic tape).
Clear destruction policies and procedures that include appropriate methods of destruction for each medium on which information is maintained.

Generally, the time medical records are kept ranges from five years to ten years after the death, discharge, or last treatment of the patient. Medical record retention time is impacted by state requirements, federal laws, and special population requirements.

State Requirements: To establish their medical record retention, healthcare organizations need to refer to their state’s specific legislation or in the absence of such laws, retain health information for the length of time specified by the state’s statute of limitations. Federal laws require that medical records be kept for at least seven years after the patient receives the treatment, though the time has been sometimes extended to 10 years.
Accreditation Agency Requirements: Accreditation agency standards also determine record retention guidelines. The Commission on Accreditation of Rehabilitation Facilities, Det Norske Veritas, Medicare Conditions of Participation, and the Joint Commission have record retention schedules in their accreditation survey processes (www.library ahima.org).
Special populations: If the patient is a minor, the provider should retain health information until the patient reaches the age of majority (as defined by state law) plus the period of the statute of limitations. For e.g., in Nevada, healthcare providers are required to maintain medical records for a minimum of 5 years, or, in the case of a minor, until the patient has reached 23 years of age. Special records retention schedule rules may apply to Medicare patients, and behavioral health or research patients. For Medicare patients, the timeline for medical record retention is ten years. The FDA requires cancer patients’ research records to be maintained for 30 years.

Types of Medical Records and Retention Policy

To create a retention schedule, hospitals have to identify their active and inactive records.

Active records are documents that are being currently utilized and consulted on an ongoing basis. For example, the records of a patient who was seen a week or even a few months ago would be considered active. However, if the patient was seen over seven years ago, then the record may be considered inactive. Other active records consulted or used on a routine basis include those pertaining to release of information requests, revenue integrity audits, or quality reviews.

Inactive records are those documents that are not being currently used by the hospital such as those of patients who has not sought treatment for a period of time or have completed their course of treatment.

Physical file space, extent of research completed, and availability of off-site storage also determine whether a record will be categorized as active or inactive. To decide when a record becomes inactive, AHIMA recommends that organizations should have a cutoff point based on the following considerations:

How often the records are accessed (daily, weekly, monthly, etc.)
The total retention requirement
Record size (large long-stay record or a short emergency record)
Physical space constraints
Activities or functions that call for routine access to the record (quality reviews, release of information)

Implementing and maintaining an effective filing system depends on identifying active and inactive records. The life cycle of a good record retention program ends when information has been destroyed in accordance with federal and state laws.

Does HIPAA have Medical Records Retention Requirements?

There is No Medical Records retention period under HIPAA and the Privacy Rule does not stipulate how long medical records should be retained. Organizations must follow the state’s laws governing the retention of medical records. However, HIPAA requires that HIPAA-related documents must be retained for a minimum of 6 years from when the document was created, or – in the event of a policy – from when it was last in effect (www.hipaajournal.com).

When it comes to medical documentation, HIPAA covers a lot of various complexities. For example, HIPAA compliant medical transcription companies that help providers maintain medical records have proper measures to ensure security, health care compliance and privacy of protected health information (PHI). Once the retention periods for medical records and HIPAA documentation has been reached, HIPAA requires physical and electronic forms of PHI to be disposed of using an appropriate destruction method.

Importance Of Accurate Documentation In Behavioral Health

20-June-2022 Rajeev Rajagopal Medical Transcription

Behavioral Health

Behavioral health specialists are focused on their patients. They have to ensure properly documented records with all pertinent and important facts to communicate information to all providers involved in the patient’s care. Most rely on a medical transcription company specialized in behavioral health documentation to ensure accurate records.

Why Proper Medical Charting is Critical

The American Professional Agency (APA), a liability insurance provider for mental health professionals, specifies that the behavioral health record should contain: a thorough history and pertinent information regarding diagnosis and treatment, assessment of suicide/violence, and medication prescriptions along with dosages. If there are any observable side effects of medications, there should be documentation that the behavioral health provider has informed the prescribing provider about it. The documentation should also include informed consent, treatment compliance/non-compliance, boundary issues, and termination. Complete, accurate and timely documentation of the patient encounter is essential for various reasons:

For provision of high-quality care: Accurate documentation is essential for the continuity of care, including providing and managing necessary services. Continuity of care implies provision of quality of care over time. It requires a physician-led, team-based approach, where the patient and the medical team cooperate to work towards meeting the goals of care.
To promote patient safety: Good documentation shows a true picture of the patient’s condition. It promotes care coordination by ensuring health information exchange on which actions have been implemented. This minimizes the incidence and impact of adverse events, and maximizes recovery.
Protects against litigation: A patient’s medical record is a legal document that can serve as the best evidence of whether the standard of care was met by the physician or nurse. Entering all information correctly in the patient record can go a long way in preventing medical errors, adverse patient outcomes and malpractice suits. Errors, oversight, or lapses in documentation can lead to adverse patient outcomes and become evidence against a provider in malpractice litigation. Likewise, proper and effective charting can disprove medical negligence.
To meet regulatory and reimbursement compliance: Regulatory compliance is the set of processes and procedures that make sure an organization adheres to the regulations, laws, and other requirements set for its industry. Healthcare organizations need to comply with hundreds of regulatory requirements, the most important being the Health Insurance Portability and Accountability Act (HIPAA), Anti-Kickback Statute and the Stark Law, Patient Safety and Quality Improvement Act (PSQIA), The Health Information Technology for Economic and Clinical Health (HITECH) Act, and Affordable Care Act (ACA).

Behavioral Health Documentation Principles

Progress notes can be written in either the SOAP (Subjective, Objective, Assessment and Plan) format or the BIRP (Behavior, Intervention, Response and Plan) format. Regardless of the format, progress notes should include the essentials and reflect the service provided and prove that it is medically necessary for reimbursement.

Following best practices is essential to prevent errors in documentation that can compromise patient care. The Centers for Medicare & Medicaid Services (CMS) has laid down the principles that behavioral documentation must meet for reimbursement. Behavioral health specialists must ensure documentation that:

Meets the State’s Medicaid program rules (if required)
Complies with the State’s definition of medical necessity and validate the treatment and clinical rationale
Provides evidence of active treatment as required under State law
Be complete, concise, and accurate, including the face-to-face time spent with the patient, such as the time spent to complete a psycho-social assessment, a treatment plan, or a discharge plan
Be legible, signed, and dated
Be maintained and available for review
Have the correct billing codes

Providers must also take care to avoid errors that can be caused by EHR shortcuts and time savers such as the cut-and-paste function, pre-populated templates, drop-down lists, auto-fill, and keyword features. The EHR should reflect the uniqueness of each encounter or the patient’s description of their chief complaint. All notes should have a date and time stamp and all edits should be attributable to the person making them.

Most healthcare compliance issues relate to patient safety, the privacy of patient information, and reimbursement for services. As psychotherapy records are subject to stringent confidentiality standards, they should be kept separate from the rest of the medical record. Failure to protect confidential patient information can result in heavy penalties from regulatory authorities.

Also Read: Accurate and Time-bound Medical Transcription Services

As patients are treated by different healthcare providers, health information should be appropriately documented and shared for proper continuity of care. While EHRs allow behavioral health professionals to improve care quality and coordination, data entry is time consuming and tedious. Medical transcription outsourcing to an experienced behavioral medicine transcription service provider can ensure timely and efficient EHR documentation assistance. Experts can reduce the documentation burden for behavioral health professionals and will also have necessary measures in place to ensure the confidentiality of patient data.

5 Reasons Why Dentists Need Medical Transcription

13-June-2022 Julie Clements Medical Transcription

Medical Transcription

Medical transcription has been practiced for many years and for dentists it is a crucial service. Medical transcription is mostly used to record what a dentist says in a patient’s file. This information is communicated with the patient, the dentist, and any other doctors who need to know about the patient’s condition. Dentists spend several hours transcribing prior treatments and examinations, but with the help of a medical transcription service, they can focus better on treating patients rather than entering data. The accuracy of this type of record keeping also prevents any inconsistencies from occurring between different offices or clinics, which can happen if each office uses its own form of reporting system. Therefore, medical transcription has become an integral part of the dental practice. It is a cost-effective way for dentists to stay organized and improve their quality of service

Importance of Medical Transcription for Dentists

Working with dental professionals, a transcriptionist converts notes from patient visits and other patient-related records into a standardized, easily accessible format. A complete patient record can help doctors and other healthcare providers to share information more effectively and arrive at the best possible treatment for the patient. Anyone with permission to examine patient information can then access the digital records. This information can also be utilized to keep track of any dental medications administered. Transcription can be done for all sorts of dental records and this includes:

Notes from the consultation
Summaries of patient visits
Notes on Progress
The results of dental X-rays and examinations
Reports on graphs
Notes or summaries of dental procedures

An accurate transcription of these records helps dentists to utilize these reports to explain something about a patient’s history or condition to another doctor or dentist who sees them during an emergency session at another office location, or as part of their treatment plan for the patient’s next visit.

Reasons Why Dentists Need Medical Transcription Service

Nursing and other related staffs can refer to the patient record for information on patient care, such as warning indications that should be investigated. It also aids in determining the exact amount supplied as well as any essential testing samples that lab professionals may request.
Medical professionals, nurses, hospital administrators, and others devote majority of their time on assisting patients while still ensuring that other tasks are completed efficiently in the background. Dentists can benefit from outsourcing medical transcription if they are tired of sitting in front of a computer screen for lengthy hours to follow a report or chart of patients. For example, if you use periodontics transcription services, you can capture medical notes, reports, and other important information using audio dictation.
Medical records that have been generated in a systematic way can be used by billing and coding personnel to make insurance claims easier to settle. Accurate medical transcription is necessary to expedite the insurance claim payment procedure, whether it be periodontics transcription or any other transcription service.
Another significant advantage of employing transcription services for dentist is the cost and time saved. For any healthcare practitioner, all you need to do is use a smartphone app to capture audio notes, and you’ll be ready to move on to your next assignment in no time.
Finally, in some circumstances, keeping medical records is required by law. In the event of a legal dispute, these documents can be quite useful. It’s simple to do with medical transcribing services.

More Advantages

Better workflow: It takes a long time to transcribe medical reports. Despite this, it’s simply one of the many things that medical assistants do in addition to fast-paced responsibilities like answering phones and scheduling appointments. When you add a sluggish task to a torrent of speedy ones, the ebb and flow of their labor is substantially slowed. A medical transcription service can help in this situation. You can eliminate one difficult chore from the many that medical assistants must manage. Allow transcriptionists to handle the medical transcripts so that your medical assistants can focus on what they do best.

Good quality control: Transcribing can be a time-consuming job, especially for medical assistants who are always tied down in other administrative duties. When transcribing errors occur, they must redo the entire process. This causes patients’ treatment to be delayed. Medical transcriptionists can accurately copy all dictations and utterances. They have the energy, patience, and attention to detail required to accurately transcribe medical records. This allows doctors to treat their patients efficiently and effectively.

So, dentistry medical transcription services are important for dental medicine because it provides detailed reports on everything from patient visits to dental procedures performed on that patient. This type of report allows dentists to keep accurate records of their patients’ treatment history and any issues that may have arisen during their visits to the office. A dentist can use these reports as part of their treatment plan for the patient’s next visit or as an aid when explaining something about a patient’s history or condition to another doctor or dentist who sees them during an emergency session at another office location.

Why Do Doctors Voice Record Their Patient Encounters?

09-June-2022 Rajeev Rajagopal Medical Transcription

Patient Encounters

Any patient encounter can be recorded and transcribed with the help of medical transcription services. Voice recording helps in documenting the medical history, treatment plan, and other details of a patient’s encounter with the doctor and it also ensures that the patient understands the complex diagnosis and treatment protocols. It is useful in cases where the doctor cannot take proper notes during the patient interview because of frequent interruptions or busy schedule and such other issues.

Professional medical transcriptionists listen to physicians’ dictations and generate accurate medical records that are very important when it comes to providing the right care and attention to patients.

Apart from providing extra information to patients and protecting patients and clinicians in the event of misunderstandings or legal action, such recordings can have some other advantages: these can be used to educate healthcare professionals; the recording of medical and nursing students’ patient talks can be used for training purposes; these records would also be useful for quality, safety, and performance improvement, as well as for research and abuse case documentation.

Five Reasons Why Doctors Utilize Medical Transcription Services for Accurate Documentation

To Ensure Patient Adherence to Medications: Medication adherence rates are at an all-time low of 50%, according to a 2016 study published in The American Journal of Medical Sciences. While many physicians felt that the low rates were due to a lack of availability (think high costs), the study discovered that the issue is more nuanced. In fact, the paper identified communication as a major stumbling block. Patients are less inclined to take a medicine if they don’t comprehend why it would help them. Medical transcripts created by professional transcription services enable patients to have a written record of why and how they should take their medicine each day. These medical transcripts can also be shared with family members to ensure better patient care.
A Feeling of Having Control: Delivering bad news is the most difficult part of a doctor’s job. When a patient is informed about his/her serious health condition, they may become overwhelmed. They may have a number of questions such as “how do I get better?” “are there successful treatments for my condition?” and so on. They may want information such as what’s next, which expert to visit, what to expect, what various outcomes might look like, and so on. Having a recording of the patient encounter and transcribing it helps the physician and the care team to have a clear idea of the patient’s health condition. Moreover, they can also clarify any doubts they may have.
Take the Conversation to a Higher Level: Doctors always face questions. Calls with follow-up questions are common from patients who keep track of their appointments. Recording and transcribing patient encounters can help respond to these phone calls. It’s no longer about re-answering the same queries a few days later, but rather about responding to fascinating, insightful follow-ups. It shows that the patients are gaining greater knowledge of their interactions and, as a result, are more prepared to consider their health more seriously in the future.
Collaboration in Health Care: Positive medical results are frequently associated with good family involvement. Patients who underwent cardiothoracic surgery and had family members active in a family support program, for example, were considerably less likely to be readmitted to the hospital, according to a 2018 study published in the Chest Journal. Patients require their families for a variety of reasons, not only surgery. Your family knows you best, for better or worse. The ability to share appointment recordings and transcripts ensures that everyone in the family is aware of any potential adverse effects from medications or symptoms that are progressing. When releasing a transcript, it allows someone in the family who has a higher level of medical literacy such as a nurse or pharmacy technician, to help explain things to other family members who may not understand.

Protecting Your Reputation: Recordings can be beneficial in demonstrating all of the things a doctor did correctly. Recording and transcribing the patient encounter brings things out into the open—much better than a patient secretly taping your conversation.

From all the above-mentioned reasons it is clear that recording and transcribing patient encounters with the help of a reliable medical transcription company enables physicians to maintain accurate medical records, and provide better patient care. Above all, the transcripts act as a proof in case of any litigation. It also helps the patients and their family to have a clear idea about the patient’s health condition, ongoing treatments, whether the treatments are effective and so on.

Medical Record Documentation – Best Practices

06-June-2022 MTS TEAM Medical Transcription

Medical Record Documentation

Clear, accurate, legible, complete and accessible medical record documentation is essential to facilitate patient care decisions and avoid treatment errors. Medical transcription outsourcing is considered a viable strategy to promote timely and accurate patient charting. However, it is the healthcare provider’s responsibility to ensure that relevant facts, findings, and observations about a patient’s medical history, including past and current illnesses, tests, treatments, and outcomes are entered in the electronic health record (EHR). Following best practices can make EHR documentation more efficient, contribute to high-quality care, protect healthcare organizations from risk of liability, and also reduce physician burnout.

Basics of Good Medical Record Documentation

Document the history and the physical examination: Elicit and document medical history, including history of present illness, chronology, modifying factors, and associated symptoms, past medical history, general health and childhood illnesses, surgeries, hospitalization, trauma, medications, allergies, family history, and social history. Documenting patient history will ensure that past and present diagnoses are available to the treating and/or consulting physician. Proper documentation is critical in emergency situations.

After obtaining the chief complaint and history of the present illness, perform and document the physical examination. The physical exam would depend on the patient’s complaint. The levels of evaluation and management (E/M) services are based on four types of examination: problem focused, expanded problem-focused, detailed, and comprehensive. Documenting the physical examination is required to communicate patient care provided among healthcare providers as well as for justifying medical billing. Whether it’s a single organ system or body area or multiple organs and body areas, document the entire examination. Organ systems, not body areas, should be used to identify the required elements. Finally, consider summarizing key history and physical exam findings so that other providers don’t have to spend too much time reading the notes.

Be cautious when using prepopulated EHR templates: Prepopulated physical exam templates enter information into the patient’s record, assuming that normal aspects of the exam were performed. Being conscious of what’s prepopulated is important so that changes specific to the patient can be made. If this is not done, the physical exam documentation may be incompatible with the chief complaint, history of present illness, or the assessment and plan.
Avoid indiscriminate use of the EHR copy-and-paste function: Using the copy-paste function to import previous notes into the current encounter has the potential to affect the integrity of the health record as the information may no longer be relevant. It can result in inaccurate coding, transmission of false information, inability to track the patient’s care, and lengthy, redundant progress notes. A cross sectional survey of resident and faculty physicians at two academic medical centers found that inconsistencies and outdated information were common (71%) in notes containing copy and paste text.
Document all provider-patient communication: Effective provider-patient communication is key to building a therapeutic physician-patient Physicians and their staff should document all communication with patients outside of the office, including phone calls and emails in their medical record. It is also important to document interactions with relatives/caregivers of patients, other medical teams, and specialists involved in the care of the patient. Summarize the main points of the discussion and who participated. As Clinical Advisor points out, this crucial to prove that you did not ignore the patient if you are deposed.
Promote documentation interoperability and transferability: It is important that pertinent information, including nursing notes, can be sent to other systems in a usable format to other systems. To facilitate interoperability and transferability, a Nursing World report states that it is necessary to use standardized terminologies to describe assessment, identification of problems, diagnoses and interventions, outcomes, evaluation, and recommendations, and also have a system in place to accurately document errors (commission, omission, and near misses) that meet a national standard.
Document future plans and objectives: Patients may see providers at other facilities for ongoing or follow-up care. Clinical documentation should communicate plans and objectives to other healthcare professionals such as life care planners, social workers, and specialists, who might care for the patient in the future. Documenting future plans will help ensure that the patient receives the follow-up care needed to fully recover or manage an ongoing condition.

Support Strategies to Improve Medical Record Documentation

Having reliable support strategies in place can reduce the documentation burden, improve productivity, and streamline workflow. Many physicians use dictation software to speed up EHR documentation. But for speech recognition to work, you would have to expand its vocabulary and train it in correct pronunciation. Getting scribe support is another option. In fact, some primary care offices that have limited staff use scribes to help with electronic documentation (AAFP). Family practice medical transcription services are also a cost-effective way to save time, improve efficiency and ensure quality medical record documentation. Experienced transcriptionists can deliver accurate transcripts of the H&P, allergy & immunization, chronic disease management, follow-up visits, and much more. Partnering with a reliable medical transcription service company can help provider focus on their patients, improve compliance, and reduce burnout.

What Are The Factors Impacting Medical Transcription Turnaround Time?

30-May-2022 Rajeev Rajagopal Medical Transcription

Medical Transcription

Medical transcription plays a crucial role in helping physicians accurately document patient information and maintain good healthcare records. Having the transcription task handled by experts can ensure high-quality, timely documentation. Turnaround time is one of the key considerations when choosing a medical transcription company.

What is Turnaround Time (TAT) in Medical Transcription?

Turnaround time refers to the window of time between the dictation of a report and when it is transcribed and returned to the client. Timely and accurate healthcare documentation facilitates continuity of care for the patient by ensuring that all providers involved in the patient’s care have the same information to help them make the best clinical decisions quickly. However, several factors can impact the turnaround time of medical transcription services.

Optimize your medical transcription services with precision and efficiency.

Medical Transcription Turnaround Time

Factors Impacting TAT and How to Minimize their Impact

From a dictation and transcription standpoint, the ideal scenario would be one in which your transcribed reports are available immediately or as quickly as possible regardless of any contracted and defined guidelines or TATs otherwise specified. However, many factors influence TAT and as a physician, you need to be aware of them when they send out your dictation for transcription.

Audio recording clarity: A good quality recording is essential for high quality medical transcription. If you are too close to the microphone, it could add plosives to your audio and make it harder for the transcriptionist to understand your speech. They would have to rewind the audio to catch the words, losing time and increasing TAT.Best practice is to hold your telephone, recorder or smartphone at the same distance from your mouth as you would when talking on the phone. Keep some distance from the device of recording equipment you’re using. Most devices will recommend the optimal distance in their manual, but you may need to experiment and find out what works best.
Speech clarity: Speaking softly, very quickly or very loudly can distort the audio. Mumbling when repeating the same procedure multiple times a day is a common challenge for medical transcriptionists. Fatigue can also alter speech patterns, leading to whispers or less clear dictation. The solution: speak clearly and at a natural pace.
Complex words: Transcriptionists may have difficulty recognizing unfamiliar words. If words cannot be transcribed, transcriptionists will leave blanks in the transcript. Documents that are incomplete will require more time to transcribe and cost more. Reliable transcriptionists refer to Steadman’s Medical Dictionary and other resources to verify spellings, highly technical medical terminologies, medical jargon, slang etc. Such research takes time. Even experienced medical transcriptionists can take a longer time to transcribe a small file with complex words.Spell out names and medical terminologies that are difficult to understand. Likewise, pay special attention to numerical descriptions and units of measure.
Environment: Physicians don’t always dictate in ideal conditions. They often multitask, dictating while eating, chewing gum, driving, or in noisy surroundings like crowded rooms or hospitals. This can impact the quality of their dictation recordings due to background noise and distractions.As far as possible, ensure you’re dictating in a quiet place without a lot of background noise. Avoid places like corridors when dictating as it can cause an echo and affect the audio. Avoid eating while dictating.
Interruptions:Engaging in a conversation while dictating will impact the recording. Interruptions happen, but make sure they don’t affect dictation quality. If an interruption occurs or you want to converse, pause the audio and resume when you’ve finished. Some systems may require you to start a new file if you hit Pause.
Multiple speakers: Doctors’ visits can have multiple speakers. Audio recordings with one or two speakers are easy to transcribe, but when there are multiple voice, the transcriptionist may find it difficult to identify each speaker. Heavy accents and speaking too fast can also cause problems. These factors can increase transcription time.

Technology can address this concern. For example, Google’s Cloud speech-to-text tool is specially designed to recognize multiple speakers in the same audio clip. Words spoken by each person such as the physician, nurse and patient, are automatically detected by the medical model for conversations and labeled in the automated transcript. Using this option can improve transcription outcomes.

Proofreading requirements: If medical transcripts contain errors, it can compromise patient safety, even with serious consequences. Leading medical transcription companies put all transcripts through a multi-tier quality check to ensure the highest level of accuracy. Regardless of the technique used, proofreading is an important consideration when it comes to TAT.

In addition to transcription anomalies, the AHIMA-MTIA joint task force’s survey identified other factors contributing to TAT noncompliance in 2008 as staffing, work volume changes, new technology and equipment installation and TAT expectation changes.

Over the years, advancements in technology and changes in regulations and reimbursements impacted TAT for different document types.

Having a good idea about the factors that influence TAT can help you address them and get the most out of your medical transcription service.

Turnaround Time

Customized Turnaround Times Prevent Backlog

Partnering with a professional medical transcription company will ensure that your medical reports are duly transcribed within the specified TAT. This can ease any chance of a backlog that needs to be tackled and also reduces the chance of data being lost. They can provide customized solutions to ensure that all reports, notes and summaries related to a particular case are well-organized, making reference easier.

Ensure accurate documentation, prevent backlogs, and prioritize healthcare with our HIPAA-compliant transcription service.

Call us at 1-800-670-2809

How Speech Recognition Supports Delivery Of Acute Care

26-May-2022 MTS TEAM Medical Transcription

Speech Recognition

The number of patients seeking care is on the rise, mainly due to the aging U.S. population and overall population growth. Clinicians are also seeing more patients of all ages with multiple comorbidities. These trends, along with staffing shortages, have made managing the electronic health record (EHR) documentation a major challenge, leading to clinician burnout and less time for patient care. Speech recognition (SR) technology along with medical transcription services can play a key role in easing EHR documentation challenges and improve acute care delivery.

Growing Demand for Acute Care

The demand for acute care will increase along with the rise in the aging population. Acute care refers to the immediate but short-term treatment provided to a patient to address a severe event brought upon by a condition, trauma, or during recovery from surgery. Acute care is normally provided in a hospital setting by clinicians experienced in diagnosing and treating a wide range of conditions, symptoms, and injuries.

According to a JAMA Internal Medicine study published in 2018, visits to acute care facilities, such as urgent care centers, grew by 140% during 2008 to 2015. New acute care options that have emerged over the past two decades include urgent care centers, retail clinics, and telemedicine.

Role of Speech Recognition in Acute Care Delivery

Dictation applications help physicians and nurses to capture and record patient diagnoses and treatment notes. SR software transcribes words as they are spoken in real-time and can ease documentation challenges for clinicians with heavy workloads. Digital speech recognition has become more prevalent in acute care settings due to certain reasons:

Captures complex patient encounters in real-time: Clinicians in acute care facilities need a variety of skills and need many different types of equipment as they see patients with different types of medical issues (www.carevoyance.com). For instance, a patient presenting with unexplained abdominal pain will need different care and tests from a patient presenting with a leg fracture. Automated dictation tools will help physicians capture encounters as and when they happen.
Timely documentation: Acute care settings treat immediate medical emergencies of all types. In such situations, timely completion of charting is critical if the chart is to be accurate. Speech recognition can improve speed and accuracy of acute emergency medical service documentation.
Significant time savings: EHR documentation using SR software takes less time to complete than typing. According to a study published by Healthcare Management in January 2022, SR software took just 5.11 minutes to complete the medical form, compared to 8.9 minutes typing.
Reduces clinician burnout: Instead of spending longer hours to complete medical documentation, SR applications allow clinicians create EHR documentation using only their voice.
Supports acute care telemedicine: In telehealth urgent care delivery, emergency care teams connect with remote acute care professionals (e.g., cardiac or trauma surgeons, vascular neurologists, intensivists) for diagnostic and treatment support. This promotes fast care delivery by improving access to care and patient outcomes.

Speech recognition solutions improve workflow by helping clinicians automate their documentation tasks making them more efficient and productive. It also helps acute care providers to deal with staffing shortages. Importantly, it allows them interact more effectively with their patients.

Artificial intelligence (AI) powered tools with voice recognition go beyond just improving patient care documentation by providing benefits such as:

Real-time evaluation of dictated content to help reduce errors and improve accuracy
Mining of key data elements from voice and entering them in specific areas within the HER
Securely capturing and documenting relevant information as it occurs during the conversation
Integrating with any EHR system for data capture
Enabling data capture from mobile devices
Enhanced chart completion compliance

According to a Healthcare IT News report, patient response to ambient technologies is favorable as it allows them to interact more closely with their provider, a relationship which was lost because of overcoming burdensome EHR documentation requirements. However, voice-enabled applications will have to overcome data privacy concerns and educate patients about ambient technologies.

Continuing Relevance of Medical Transcription Services

Even with the widespread adoption of electronic health records and speech recognition technology in acute care settings, the services provided by medical transcription companies continues to be important for error-free EHR documentation.

SR-generated documents tend to have errors. A 2018 study that analyzed the quality of SR-assisted documentation found that seven in 100 words in SR-generated documents had errors. Mistakes created by the SR tool can be very difficult to identify. That’s why experts recommend back-end SR, which involves medical transcription services.

In contrast to front-end SR which takes place real-time, back-end SR involves recording the dictated words and then converting the recording into text. In this scenario, the draft document and recording created by the SR software is sent to a medical transcriptionist for review to ensure accuracy. Leading service providers have teams trained to provide documentation for various specialties, such as cardiology and neurology transcription services. The quality assurance provided by experienced medical transcriptionists can go a long way in improving the quality of SR-generated patient records.

Ambulatory EHR Market Size To Reach USD 6.8 Billion By 2025

23-May-2022 Julie Clements EHR Transcription

Ambulatory EHR Market

Ambulatory EHRs help in the faster exchange of healthcare details and enhances communication among healthcare providers. EHR systems are used in outpatient and inpatient settings. Ambulatory settings require the EHR to access crucial patient data from different providers and labs. EHR-integrated medical transcription services ensure accurate clinical documentation and helps ambulatory physicians focus on delivering quality care.

Ambulatory EHRs support outpatient healthcare needs such as office visits and ongoing prescriptions. These EHR systems make it easy for physicians to track patient records and long-term care. They can collect detailed, specific information about each patient, and ensure complete and accurate health records.

Key Factors Driving Ambulatory EHR Market Growth

According to a Markets and Markets research report, the global ambulatory EHR market size is projected to reach USD 6.8 billion by 2025 from USD 5.2 billion in 2020, at a CAGR of 5.7% during the forecast period.

Growth in the global ambulatory EHR market can primarily be attributed to factors such as

increasing adoption of EHR solutions coupled with incentives and payment adjustments
government support for the adoption of EHR solutions
increasing number of outpatient care centers
growing patient volume due to the global outbreak of COVID-19, and
the need to curtail healthcare costs

However, market growth is limited by factors such as reluctance to adopt EHR solutions in developing countries, heavy infrastructure investment, and the high cost of deployment.

The report segments the market on the basis of deployment, application, practice size, end user, and region.

By deployment, the market is segmented in to cloud-based and on-premise solutions. The cloud-based solutions segment is projected to grow at the highest CAGR during the forecast period, mainly owing to its advantages including flexibility and cost reductions in healthcare delivery.

By application, the market is segmented into Practice Management, Patient Management, e-Prescribing, Referral Management, Population Health Management, Decision Support, and Health Analytics.

By practice size, the market includes Large Practices, Small-to-Medium-sized Practices, and Solo Practices. The large practice segment commanded the largest share of the market in 2019, owing to factors such as the availability of capital investments, the ability to handle productivity challenges that are created by new EHR adoption, and the ability to choose among vendors. However, small-to-medium-sized practices are expected to register the highest CAGR between 2020 and 2025, owing to extensive funding provided by the Regional Exchange Centers (REC) to support small-to-medium-sized practices in the adoption of EHR.

End-users of the market include Hospital-Owned Ambulatory Centers and Independent Centers. Geographically, the market is divided in to North America (US, Canada), Europe (Germany, UK, France, Italy, Spain, Rest of Europe), Asia Pacific (Japan, China, India, Rest of Asia-Pacific), Latin America, and Middle East & Africa. The Asia Pacific region is expected to show the highest growth rate during the forecast period, due to factors such as increasing incidences of chronic diseases, the rising geriatric population, growing demand for advanced healthcare systems due to increasing per capita disposable incomes in the region and growing awareness of EHR solutions among healthcare providers.

Key Players Competing in the Ambulatory EHR Market

Some of the key players competing in the ambulatory EHR market are Epic Systems Corporation (US), Cerner Corporation (US), Allscripts Healthcare Solutions (US), Medical Information Technology, Inc. (MEDITECH, US), CPSI (US), NextGen Healthcare Information Systems, LLC (US), eClinicalWorks (US), athenahealth, Inc. (US), Modernizing Medicine, Inc. (US), Medical Transcription Billing Corporation (MTBC, US), Amazing Charts, LLC (US), Greenway Health (US), eMDs, Inc. (US), NetSmart Technologies (US), and CureMD (US). Players adopt diverse growth strategies such as partnerships, agreements, collaborations, new product launches, and acquisitions to increase their presence in the global ambulatory EHR market.

Physicians can ensure error-free EHR-integrated medical documentation with support from an experienced medical transcription company in the USA.

How To Document Pain Assessment

19-May-2022 Rajeev Rajagopal Pain Management Transcription

Pain Assessment

Pain affects more than 100 million Americans and costs more than $600 billion annually, according to a new study published in Pain Physician. Reports from The American Academy of Pain Medicine indicate that the financial impact of chronic pain on the US economy is greater than diabetes, heart disease and cancer combined. As pain medicine specialists strive to provide quality care, they have to pay attention to the financial aspects of their practice. Accurately documenting the patient’s pain is essential to improve coding and maximize reimbursement. Pain management transcription services play an important role in helping physicians ensure complete, accurate and up-to-date clinical documentation.

Telling the Patient’s Story with Detailed Documentation of Pain

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Thorough, detailed documentation of pain is crucial for the following reasons:

Assists in diagnosis and development of an effective treatment plan
Supports continuity of care by providing detailed better, more effective information to other health care providers treating the patient
Leads to accurate coding for appropriate and timely claims payments

What should the documentation include? As pain is multidimensional, the assessment of pain must include the intensity, location, duration and description, the impact on activity.

PQRST for Pain Assessment: As pain is a subjective and a unique subjective experience with multiple dimensions that may not be directly apparent to others or measured by physiological tests, pain assessment depends significantly on self-report. The PQRST method is considered the Gold Standard to assess and document a patient’s pain.

Precipitating and relieving factors – The patient is asked what they were doing when the pain started, what caused the pain, what makes it better or worse, and what seems to trigger it.

Quality – What is the quality, character, and intensity of the pain – sharp, dull, burning, or other?

Radiate – Ask the patient if the pain is localized or moves to other sites, and if so, where else they feel pain.

Severity – The patient is asked to rate the pain on a scale of 0 to 10, where 0 is no pain, and 10 stands for the worst pain ever.

Timing – Questions relate to all temporal aspects: When/at what time the pain started, duration, frequency, such as hourly, daily, weekly, or monthly, if it is sudden or gradual, whether it is seasonal, and so on.

In addition to the severity, variability, patient’s movements at pain commencement, location, and time of pain onset, the physician should also document the evaluation of pain site. This assessment should describe any swelling, deformity, bruising, tenderness, and so on.

Point to note: While a self-report by the patient has conventionally been the basis of pain assessment, communication barriers such as cognitive impairment or language barriers can make this difficult. Caregiver reports may be used as a proxy in such situations. As pain is also difficult to measure accurately and reliably in children, parents or family caregivers may have to be involved in the assessment.

Progress Notes to Chart the Patient Experience

One of the most important documents that a medical transcription service company helps pain specialists create is the progress note. It is essential that pain assessment is done on a regular basis using a standard format to monitor the patient’s progress. It involves documenting pain after each intervention to assess its impact, understand the patient’s experience, and determine whether the treatment should be modified.

Progress notes document the patient’s recovery and care and serve as a record for the patient’s time spent in the hospital’s or clinic’s care. Healthcare professionals use the SOAP method (subjective evidence, objective information, assessment, and care plan) to write progress notes. Progress notes can also include an interventions section where nurses can include additional information about interventions such as medications administered during their shift and observations made about the patient.

However, medical records often miss circumstances, details and nuances and this loss can be more pronounced in patients dealing with pain. Recent studies have found that applying natural language processing (NLP) technology to an EHR dataset could successfully and efficiently capture detailed pain information from clinical notes (Automated Extraction of Pain Symptoms: A Natural Language Approach using Electronic Health Records (Pain Physician, 2022).

Role of Pain Management Medical Transcription Services

Pain management has extensive documentation requirements when it comes to insurance payment. For instance, take Medicare requirements for chiropractic services. Medicare requires that the record should document symptoms that bear a direct relationship to the level of subluxation. The symptoms should refer to the spine, muscle, bone, rib and joint and should be reported as pain, inflammation, or as signs such as swelling, spasticity, etc.

In addition to documentation of subluxation shown by x-ray or physical exam, the documentation must show at least 2 elements of:

Pain
Asymmetry/misalignment
Range of motion abnormality
Tissue tone changes (P.A.R.T.), including 1 that falls under asymmetry/misalignment or range of motion abnormality
Include dated documentation of the first evaluation
Include primary diagnosis of subluxation (including level of subluxation)

The provider should also include any documentation supporting medical necessity

Medicare also requires that family and past health history, including general health, prior illness, injuries, hospitalizations, medication, and surgical history be elicited from the patient and documented on initial examination.

Extensive documentation requirements can take up physician time. Medical Economics recently reported on a new study which found that physicians spend an estimated 4.5 hours a day completing electronic health records (EHR), which “leaves less time to attend directly to patients” (www.medicaleconomics.com).

Partnering with a medical transcription company that specializes in pain transcription is a practical solution to this problem. Experts can ensure consistent, accurate and timely EHR documentation, allowing physicians to focus on their patients.