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.

Key Tips To Write Open Clinical Notes [INFOGRAPHIC]

16-May-2022 MTS TEAM Infographics

In any medical practice, sharing open notes benefits both patients and clinicians. Professional medical transcription companies can help healthcare providers to create different types of clinical notes such as consultation, discharge summary, procedure notes, progress notes, history and physical, imaging narratives, laboratory report narratives and pathology report narratives. Such companies provide the services of experienced medical transcriptionists and quality assurance professionals who can ensure error-free documentation in the electronic health records (EHR), thereby reducing the likelihood of errors in open notes.

Check out the infographic below

Open Clinical Notes

Read our blog on Points To Improve The Quality Of Open Notes And The Role Of Medical Transcription Services In It

Strategies To Grow Your Medical Practice

12-May-2022 Rajeev Rajagopal Medical Transcription

Medical Practice

Starting a medical practice and growing it is a daunting task, more so in these challenging times. A medical practice is a business like any other and physicians have to play many additional roles, such as entrepreneur, manager and CEO. Attracting new patients and retaining existing ones is essential for a practice to grow and thrive. Having the right support in all areas is also crucial. For instance, outsourcing medical transcription helps physicians maintain accurate, consistent and timely EHR documentation to convey all the information necessary for clinical management and reimbursement. Medical transcription services are just one cog in the wheel.

Strategies and Tools That Physicians Can Use

There are many strategies and tools that physicians can use to grow their practice.

Build patient loyalty: Whether you’re a family physician, dentist, or orthopedic specialist, having a loyal patient base is essential for the stability, consistent profitability and growth of your practice. Here are 5 ways to boost patient loyalty:
- Monitor patient satisfaction – conduct surveys or ask for patient feedback to understand their needs, what they like about your practice/services, and also what irks them so that you can provide solutions
- Keep lines of communication open, make sure care personnel/customer care support are available on the phone
- Keep in touch with patients between visits and convey tips and health advice via email and newsletters
- Simplify appointment scheduling and address long wait times
- Respond to patient reviews on social media

Having a sound patient retention strategy is important for two reasons: it costs more to acquire customers than to retain them, and having loyal patients can increase referrals, which are crucial for any healthcare business.

Hire the right people: Having friendly, efficient staff is paramount to grow your practice. It’s important to deliver a quality patient experience and also to manage the administrative and financial aspects of your business. Medical Economics reports that some 57%of physicians report feeling burned out or depressed in some way, with 56% of that set attributing the bulk of their troubles to “bureaucratic tasks.”

Choose the right team. Hire professionals with the personality, skills and passion to take your business forward and can help your practice survive and flourish. Whether you’re adding a partner, hiring a nonphysician provider, or an office manager, a Medical Economics article recommends focusing on hiring “high-quality staff for sustainable growth”.

How much support staff does a physician need? Well, almost every specialty has benchmarks for this. For instance, a primary care provider that relies on a family practice medical transcription service provider to maintain well-organized EHRs may require fewer support staff than one who is less organized. Likewise, with the right medical billing outsourcing company, practices can reduce revenue cycle management burdens, better handle the prior authorization process, and improve physician well-being.

Support your team. Studies have found that employees who are confident and happy in their role perform better. For instance, training on phone etiquette can be extremely useful for your front desk staff. Providing additional coaching and training can increase return on investment. A study by research consultancy group Accenture found that for every dollar invested in training, companies received $4.53 in return, which is a 353% return on investment (ROI).

Showcase your brand: Just like other businesses, your medical practice needs to develop a brand and showcase it. Identify what’s unique about your practice and work with your team to develop a strong branding message that aligns with your corporate philosophies, operating systems, and guiding principles. As most people rely on Facebook and Twitter to find medical services, a social media presence is an effective way to connect with and attract new patients and build your brand. When you showcase your message on social media, remember to present it in a way that it’s a promise and not a pitch.

Invest in technology: Investing in the latest technology is important to stay competitive. A 2021 HIMSS Future of Healthcare Report noted that 80% of healthcare providers plan to increase investment in technology and digital solutions over the next five years. A 2022 Forbes article predicts continued growth in telemedicine, personalized medicine, genomics, and wearables. Artificial intelligence (AI), cloud computing, extender reality (XR), and the internet of things (IoT) are being leveraged deliver these services. Video conferencing proved a great way to build life-long relationships with patients and families during the pandemic and allowed practices to maintain continuity of care with patients and, in some cases, engage new patients. Video visits are also more efficient than in-person consultations as they allow a provider to see more patients in the same period of time. New laws have increased telehealth reimbursement for qualified professionals such as occupational therapists, physical therapists, speech-language pathologists, and audiologists. With telemedicine, practices can enjoy revenue growth without the need to hire additional providers, office staff, or office space.

Educate patients: Patient education is essential for practice growth. By identifying specific issues to address with each patient, you can personalize patient education and build patient loyalty. For instance, an ophthalmologist can personalize education for a millennial patient who works on a computer by explaining how blue-light filtering lenses can decrease eyestrain and recommending how to address the problem. By educating patients on solutions for their specific problems and needs, physicians can grow your practice and retain their patients.

Prepare for financing processes: Financing is a critical aspect whether you are setting up or acquired a new practice or evaluating your existing financial options to grow your business. In addition to a robust advisory team, you need a proper business plan, as well as budgets, requisite documentation such as historical and current financial details (depending on circumstance), and specs to support your financing request. With a reliable lender, and solid team and documentation in place, you will be ready to grow your practice

Why Consider Outsourced Medical Transcription Service?

Finally, consider outsourced medical transcription services to maintain precise documentation, reduce overhead expenses, and free up time and resources. Partnering with a medical transcription company that can provide EHR documentation specific to your specialty can help you work smarter, focus on patient care, and grow your practice.

Is Medical Transcription Still Relevant In 2022?

09-May-2022 MTS TEAM Medical Transcription Outsourcing

Medical Transcription Still Relevant In 2022

Medical transcription has undergone tremendous changes over the years. The introduction of the EHR system made a huge impact on medical transcription and many believed that medical transcription would fade away with time. While the adoption of EHR promised substantial benefits to both healthcare professionals and the patients, it also had some serious unintended consequences and this has led to the continuing need for medical transcription. Medical transcription services help with the collection of patient narratives, documentation of medical records, and make the patient’s record in the EHR more complete. This means medical transcription still plays a crucial role in medical documentation which is used as a base for coding and insurance processing, and also helps with revenue generation for healthcare organizations.

Physicians spend most of their time writing notes and recording patient information. This takes away a huge amount of time that could be spent talking to patients or treating them; it also affects the quality of patient care. Medical transcription provides an efficient solution by converting doctors’ audio files into text format and storing them in a centralized location without any hassle. Medical transcriptionists can access a doctor’s recorded files on a cloud platform and transcribe them into text format within a few minutes. The doctor can then review the transcribed files for any errors or modifications.

When a patient visits a doctor, the physician records every detail such as the physical condition of the patient, her medical history, lab and pathology reports, tests, given medicines, and diagnoses into an audio file. These audio files are transcribed by experienced medical transcriptionists. They follow multi-tier quality check to ensure accuracy. With HL7 integration, the transcription providers can upload the transcribed medical reports into the physicians’ EHR. This allows physicians to access the EHR records anytime. The transcribed notes not only help with patient care, but also help in obtaining quick reimbursement of medical claims, and also help with medico legal issues. The following are some of the ways in which medical transcription helps the healthcare industry:

Facilitates collaboration: Be it large hospitals or small medical clinics, doctors always aim at listening to and curing the patients’ health concerns and also record accurate patient data, which is the most vital element for providing patient care. The patient may sometimes need expertise from diverse medical disciplines. Doctors from different specialties may need to work together to provide the best treatment plan and save the patient. In such situations, having a clear and accurate medical record and treatment information ensures that the communication between different practitioners is crisp and vibrant and they understand the treatment plan well.
Useful for Insurance settlements: As mentioned earlier, accurate medical records ensure that proper patient care is provided around a comprehensive medical staff, and healthcare providers are protected from legal conflicts and lawsuits. Reliable and compliant medical documentation is not just used for providing better care to the patient, but it is also important for the operations and maintenance of your healthcare organization. The billing and coding staff use transcribed medical records to bill insurance companies. Therefore, it is important to ensure that the medical records are accurate.
Ensures utmost accuracy: Delivering correct treatment to the patient is important and with accurate transcription, it is easier to manage patient records and their treatment. The transcripts include the present health status of the patient and measures to cure the disease, and also expand the efficiency of medical practitioners.
Helpful to support staff: Transcription provides instruction to the supporting medical staff. In the absence of the doctor, the nurses and the compounder use medical transcripts as a guide to provide the right treatment and care. It also helps them to look for any warning signs or symptoms and follow the exact dosage of medicine prescribed. So with accurate medical records, the nurses or the compounder can also provide the right treatment in case of any emergency.
Saves valuable life: In some critical cases, the patient may be sent to other countries for better patient care and treatment solutions. In such cases, multi lingual transcription of medical records is important to help the doctors provide precise treatment to the patients. The transcribed medical record also helps the doctors to understand the current status of patient’s health, medicines they are prescribed and an account of the illness. Most of the time, a patient is treated by more than one healthcare provider and with error-free transcribed notes, the communication between the doctors becomes smooth, and it also helps to save the patient’s life.

All the above-mentioned points show that medical transcription still plays a crucial role in the healthcare sector. Right from adopting the latest technologies to improving patient care, the healthcare industry has been undergoing a massive transformation to overcome its challenges and provide high-quality care. Amidst these challenges, outsourcing medical transcription plays an important role in easing the workload of doctors and improving patient care.

Speech And Voice Recognition Market Predicted To Expand Rapidly

05-May-2022 Julie Clements Medical Transcription Outsourcing

Many industries use speech recognition technology to convert spoken audio into text. Speech recognition devices have the capability to respond to voice commands and transcribe audio recordings into reports quickly and efficiently. Physicians use the technology to transform dictation into text in real-time during the consultation and usually rely on a medical transcription company in U.S. for editing and proofreading the machine-generated reports.

According to a recent report from Meticulous Research, the global speech and voice recognition market is expected to grow at a CAGR of 17.2% from 2019 to reach $26.79 billion by 2025.

The key factors contributing to the growth of speech and voice recognition technologies market during the forecast period are –

rising acceptance of advanced technology together with increasing consumer demand for smart devices
a growing need for personal data safety and security
increasing use of voice-enabled payments and shopping by retailers
consistent proliferation of advanced technologies, such as artificial intelligence and machine learning
speedy expansion of the smart devices market, and
increasing willingness to employ voice assistants on websites or physical shops

However, the report notes that there are factors that can hinder the market growth, such as high cost of voice or speech-enabled smart devices and reluctance towards adopting smart technologies, especially in elderly consumers.

The market is divided on the basis of function, end-user, technology, and geography. By function, the speech recognition market is classified in to – Automatic Speech Recognition, and Text to Speech. The voice recognition market is divided in to Speaker Identification, and Speaker Verification.

End-users of the market include diverse industries such as – Automotive, Healthcare, BFSI, Education, Hospitality, Government and Public Services, Manufacturing/Enterprises, Retail and E-Commerce, Legal, Consumer Electronics, and Military and Defense. The healthcare sector is expected to lead the industry growth. Voice recognition technology provides a precise identity verification solution that can easily be integrated with different healthcare equipment and platforms to enable secure authentication. These technologies also enable doctors to translate their voice into text, which is then documented in advanced electronic health record system. Factors such as – many companies working towards developing voice-enabled devices for the healthcare industry and the growing adoption of voice or speech-enabled EMRs is expected to drive the healthcare industry to register the fastest growth in the market over the coming years.

By Technology, the market includes both Artificial Intelligence, and Non-Artificial Intelligence. AI-integrated voice and speech recognition technologies are witnessing a robust growth. Businesses can use AI to improve the utility of any data or technology by identifying and eliminating fraudulent transactions, incorporating self-operating and self-regulating environment, and enabling predictive model with low maintenance cost. Incorporating AI with voice and speech recognition technologies helps in building a healthy customer or user insight driven platform. Being a self-learning platform, AI enabled solutions also help enhancing language processing capabilities of these solutions. Such benefits are ever more transforming the market landscape, with number of retailers increasingly incorporating AI in their solution offerings.

Geographically, the market is categorized into North America (U.S., Canada), Europe (Germany, France, U.K., Italy, Spain, and Rest of the Europe), Asia Pacific (India, China, Australia and New Zealand, Japan, and Rest of Asia Pacific), Latin America, and Middle East and Africa. The Asia Pacific speech and voice recognition market is predicted to grow at the highest CAGR. The region is currently experiencing notable growth in several industries including automotive, consumer electronics, healthcare, education, BFSI, and retail. While this growth is largely driven by the economic growth and increasing spending power, it is also contributing to the technological evolution of several industries in the region. It is also predicted that the Asia Pacific region will register accelerated growth in the global market over the coming years, owing to factors such as – growing demand for connected cars, smart technologies, and high-level safe verification devices; increasing adoption of teaching aid and evaluation systems especially in China; and increasing usage of smart devices such as smartphones and smart speakers by young consumer groups.

The major players operating in the market include Nuance Communications (U.S.), Google LLC (U.S.), Apple, Inc. (U.S.)., Amazon.com, Inc. (U.S.), Microsoft Corporation (U.S.), IBM Corporation (U.S.), iFlytek (China), Baidu (China), LumenVox LLC (U.S.), Sensory, Inc. (U.S.), Sestek (Turkey), and Dolbey Systems, Inc. (OH), among others.

In addition to convenience, voice and speech recognition technology comes with benefits such as – increased speed and accuracy, better security features, and overall improved efficiency. In the healthcare sector, medical staff can free up time spent on data entry by voice-typing their documentation and focus on their patients. Practices can also consider outsourcing medical transcription tasks to get their voice-to-text documentation done by experts.

How Can A Virtual Office Assistant Help A Medical Practice?

02-May-2022 Rajeev Rajagopal Medical Transcription

Virtual Office

Proper staffing plays a key role in helping medical practices provide a safe work environment for healthcare personnel and for safe patient care. However, healthcare staffing shortages, an impact of the COVID-19 pandemic, continue to be a concern for practices. Hiring virtual assistants can fill the gap and help practices improve efficiency and workflow. For instance, medical transcription services are a practical option to document patient visits virtually and ensure accurate and timely electronic health records (EHRs). Today, practices are even using AI assistants for a range of other clerical tasks.

Reports: Staffing a Major Challenge for Medical Practices in 2022

A September 21 MGMA Stat poll found that staffing was the biggest pandemic challenge for 73% of medical practices as they headed into 2022. Up to 41% of respondents reported their staff turnover rates rose in the past quarter, compared to 33% who said it stayed the same and 26% who reported turnover recently slowed.

The American Medical Association (AMA) reported on statistics from the Kaiser Foundation and McKinsey & Co which showed how the pandemic had impacted the health care workforce:

About one-third of doctors and nurses said they intend to reduce work hours in the next 12 months
62% said worry and stress from the pandemic has affected their mental health
About 22% of nurses said they may leave their jobs in the coming year
69% of health care executives fear nursing shortages are worse than a year ago.

Medical practices have to find a way to deal with potential staffing shortages and have processes in place to ease these shortages and reduce inefficiencies. Getting virtual support can provide the solution by allowing practices to ease their daily administrative tasks and do more with fewer people in the office. Virtual medical transcription service providers can help physicians tame their EHRs and spend more quality time with their patients.

Role of a Virtual Medical Assistant

A dedicated virtual assistant can support medical practices in the following ways:

Schedule patient appointments: With a virtual assistant, you no longer have to put your patients on hold when they call to book an appointment. Your virtual assistant is readily available to answer and return phone calls, transfer the call to the appropriate personnel if needed, help patients schedule online appointments, and provide you with easy access to patient appointments. Your virtual assistant will retrieve messages, and send confirmation emails and reminders.
Inbox management: Every day, physicians need to manage a flood of mail, including incoming requests for medical records, lab orders, responding to individual text messages, online prescription refill requests, diagnostic reports, prescription refills, and other electronic communications. A virtual office assistant can tailor inbox management to meet the specific needs of individual physicians or practice groups and help them stay on top of these critical tasks.
Insurance Eligibility/Prior Authorizations: Verifying patient eligibility ahead of the appointment is essential for accurate claim submission and reimbursement. A remote virtual assistant will access insurance portals and call insurance companies to confirm patient eligibility for tests, procedures, surgeries, and other treatments as well as obtain advance approval from a health plan before a specific patient service is delivered.
Coordinating Referrals –Coordinating patient care for specialty referrals is a major task in primary care. Virtual assistance for this task involves setting up of referrals and communicating with consulting providers after appointments to get consultation and diagnostic reports, labs studies, and other records, and integrating them into the referring provider’s EMR.
Responding to patient queries: To stay on track, patients need answers to their health-related queries. A virtual health assistant will respond to voice or text questions via mobile devices, social media, and emails. It will provide patients 24/7 access to current information, specific to their age and situation. With a virtual assistant, practices can increase patient engagement and enhance self-management skills for chronic disease.
Helping patients navigate video visits: A new study found that a medical assistant can help patients participating in video visits through the technology and provide encouragement and a human connection. According to Kaiser Permanente research published April 11 in JAMA Internal Medicine, patients participating in video visits with their primary care doctors in fall 2020 benefited from having a medical assistant help connect the call, particularly if they needed language interpretation or lived in a low-socioeconomic-status neighborhood (https://www.eurekalert.org/news-releases).
Maintaining and managing the patient database: When patient health information is buried in lengthy medical records, physicians find it difficult to absorb and access important data in a timely manner. Trying to find the information they need during the consultation can impact the time they have to actually speak with the patient. Hiring a virtual assistant can help physicians manage the patient database and retrieve the information they need easily.

Virtual assistance is also available for social media management, invoicing and billing, and medical charting or transcription. Natural Language Processing (NLP) and Machine Learning (ML) are speech recognition solutions that have revolutionized EHR documentation or transcription by reducing the need for typing. Today’s healthcare virtual assistant solutions allow physicians to interact easily with the EHR to schedule appointments, search charts, write orders, view lab results without touching their keyboard. Nevertheless, the human touch continues to be important when it comes to creating error-free EHR documentation.

Top Benefits of Virtual Support for a Medical Practice

Increase face time with patients: Hiring a virtual medical assistant will reduce your workload, especially that related to documentation, which will give you more time to dedicate to patient care. By handling tasks such as documenting symptoms and medical history, a virtual assistant will allow you to save time, spend more time with each patient, and even see more patients.
Cost-effective solution: With a virtual assistant, you save costs associated with hiring more office space or buying office equipment like computers and supplies. You only pay for the number of hours of remote virtual assistant support used. You also save on fixed salaries you would have to pay full-time staff, including health insurance and unemployment insurance. You get all the support you need with greater efficiency and no added expenses. In fact, hiring a well-trained remote office assistant is an ideal option for new practices with budget limitations.
Improved service quality boosts patient experience: Having a virtual assistant to handle emails, phone calls, appointment scheduling and insurance verification, your staff would be free to focus on patients. This will improve the quality of services and increase patient satisfaction. Moreover, your remote office assistant would always be available to answer their questions, which will greatly improve the patient experience and your communication with them. You can provide more personalized services with a virtual medical office assistant.
Round-the-clock support: If you run a busy medical practice, you can hire round-the-clock virtual support. Remote medical assistants are flexible in their working hours and can adjust their schedules to meet your requirements.
Boost your online reputation: Specialized virtual medical assistants can also help manage your digital marketing campaign and social media presence. By managing your online marketing efforts, your remote assistant can boost your brand and your reputation.
Improve productivity, efficiency and revenue: By saving time and creating workflows and processes that can boost physician and staff productivity, virtual office assistants can increase practice efficiency and revenue. With efficient insurance verification and preauth processes in place reduces risk of claim delays and denials.
Reduce stress: According to Medscape’s Physician Burnout and Depression Report 2022, burnout has increased. While 42% of physicians reported that they are burned out in 2021, this year that proportion is 47%. Burnout among emergency physicians rose from 43% last year to 60% this year. Virtual medical office assistance plays a major role in reducing provider stress by taking care of burdensome tasks and freeing up physicians, allowing them to relax and improve work-life balance.

Seamless Support for Medical Charting

One of the areas where virtual assistance is thriving is medical transcription. With the support of a virtual medical transcriptionist, physicians can effectively manage important but time-consuming tasks such creating detailed patient reports, exam notes, discharge summaries and other documents. Medical transcription virtual assistants can provide EHR-integrated documentation solutions for various specialties including family practice transcription, pathology transcription HL7 transcription, discharge summary transcription, radiology transcription, emergency room transcription, and more.

To get the most of virtual medical office support, partner with an experienced service provider.

What Are The Benefits Of A Specialty-Specific EHR For Orthopedic Practices?

28-April-2022 MTS TEAM EHR Transcription

Orthopedic Practices

Orthopedics is one of the most complex medical specialties. From knee and hip replacements to sprains and fractures, orthopedic doctors provide treatment for a wide range of problems related to the musculoskeletal system. Other orthopedic surgeries are also becoming more frequent with an ageing population. This calls for accurate medical transcripts for orthopedics, and electronic health record software is now available to support your specialty. This specialty EMR provides a specific set of clinical documentation requirements when it comes to EHR software.

It has customized templates, reducing data entry and documentation responsibilities, and allowing physicians to spend more time treating and caring for patients. EHR-integrated medical transcription provided by medical transcription services ensures accurate clinical documentation and also helps physicians to interact more with patients and focus more on improved patient care.

A specialty electronic health records platform created by practicing orthopedic surgeons for practicing orthopedic surgeons would be the most ideal option. It would intuitively adapt to your particular style of practice, remember your preferences, and facilitate clinical cooperation to streamline your entire process.

Advantages of Specialty-specific EHR for Orthopedics

Includes orthopedic specific plan and other requirements: There is no such thing as a one-size-fits-all solution when it comes to an orthopedic EMR system. You can better analyze the EMR system that meets your needs after taking the pulse of your practice and identifying the clinical, financial, and operational areas that need to be enhanced and implement an effective growth strategy. For instance, using software developed for family physicians is probably not the ideal choice for your orthopedic practice. You should look into orthopedic EMR software.

Typically, advanced orthopedic EMR systems are developed to think like orthopedic surgeons. The software or digital assistant provides orthopedicians with a list of chief complaints, thousands of diagnoses with ICD-10 codes, and a number of treatment plans and procedures right out of the box.

Improves accessibility and mobility: With a secure internet connection, you may view your patients’ records from practically anywhere at any time using a cloud-based EMR system. Even when you’re not at work, it gives you more mobility and accessibility. Pocket digital assistants and software allow you to access your EMR system while on the go. Even when you’re not at work, it gives you more mobility and accessibility.
Better efficiency: Technology helps to improve the efficiency of any organization. Specialty EHR, with its adaptive learning, understands your personal style of practice remembering your preferences and assisting in clinical collaboration, streamlining your procedure. Based on the exam, orthopedic electronic health record systems will recognize the most common diagnoses and the specific way in which you usually treat these diagnoses. For example, when a physician does a knee exam, the electronic medical assistant (EMA) will fill the 10 most typically treated knee diagnoses based on the choices of the specific provider.

EMA recalls the frequent diagnosis-specific observations if the physician selects a knee arthritis impression. The system will also display the physician’s preferred treatment plans for knee arthritis, such as steroid injections, surgical discussion, prescriptions, and physical therapy. EMA adjusts to each provider’s preferences on the fly, making it easy to adapt to your clinic. EMA is equipped with built-in ICD-10 orthopedic codes gathered during the patient contact, which can help automate notes and billing.

Access to all-in-one orthopedic software: When it comes to orthopedic software, there are so many choices that you can’t go wrong. For your EMR system, practice management, revenue cycle management, billing, and even analytics, you might choose a different vendor. Different vendors can be used, but managing multiple points of contact, implementations, and bridges can quickly become a nightmare, resulting in extra labor, increased costs, and confusion. There are orthopedic software solutions that are all-in-one and can help you streamline your practice. This creates a one-stop shop for orthopedic software that is fully integrated.
Helps to provide value-based medicine: Specialty-specific EHR such as orthopedic EHR can help simplify processes related to the Merit-based Incentive Payment System (MIPS). It helps track your projected Composite Score and has built-in analytics and benchmarking reports to simplify data submission. Advanced technology assists in obtaining appropriate reimbursement for services provided.

Participates with specialized health registries: In the age of value-based medicine, the opportunity to conveniently join in orthopedic-specific health registries becomes invaluable. Having access to such specialist health registries can help you comply with MIPS and receive extra points, which can help you avoid penalties and income loss. It may even boost your earnings by providing incentives for upward changes. With just a few clicks, you may join specialist registries and begin using them.
Use the power of healthcare analytics: With technology you can dive into data like you never could with a paper chart. Invest in an EMR system for orthopedics that captures organized and usable data at the point of care. This data should be collected without the need for additional personnel or time; it should be seamlessly integrated into your orthopedic EMR system, allowing your present team to work more efficiently. Actionable data can be used for a variety of objectives, including billing accuracy, group analytics, and research. Access to Analytics allows for near-real-time comparative benchmarking of individual clinician and practice performance, as well as identifying areas where you may be falling short of other orthopedic surgeons. Having this information can help you in strategizing and identifying areas where you shine and grow.
Provides an experienced support team: Whether it’s your first day or you’ve been a client for a long time, the customer care team should enhance your experience and assist you in using best practices and the latest features. Access to a variety of training choices, a knowledge base, and the ability to contact a responsive support team during business hours all work together to help you get the most out of your orthopedic EMR system.
Helps to build trust with your patients: Using cutting-edge technologies can set you apart from other orthopedic practices. You want your patients to advocate for you and your office in the age of social media and online reviews, so give them more reasons to do so. Patient engagement technologies can help you strengthen and establish trust with your patients, offering them a better office experience and the opportunity to be more involved in their own treatment.

Using EHR software for orthopedics will increase your staff’s productivity and speed up workflow, from diagnosing and treating muscle injuries to supporting patients with difficulties with the torso, spine, skull, hip, knees, shoulders, and extremities. In addition, your clinic will be required to set up and supervise ongoing physical therapy sessions on a regular basis. This means you’ll be able to spend more time on actual patient care and free up staff resources so you can see more patients each day. Specialty-specific EHR helps to have a robust orthopedic practice management system that helps to more efficiently and effectively manage the workflow in your medical practice. A reliable orthopedic medical transcription company provides EHR-integrated medical transcription facility that helps physicians to have an accurate EHR and also focus on patient care.

How To Improve Productivity And Patient Care By Outsourcing Medical Transcription For Physicians

25-April-2022 Julie Clements Medical Transcription

Outsourcing Medical Transcription

Physician burnout, also referred to as “physician fatigue”, is a state of emotional, mental, and physical exhaustion caused by long-term involvement in repetitive and emotionally demanding situations. Physician burnout has an impact on not just their work performance but also the quality of treatment they deliver to their patients, which is quite worrisome. The demand for copious medical documentation is a major cause of physician burnout. One of the best ways to prevent physician burnout is outsourcing medical transcription to a reliable service provider who can assist physicians in drafting error free medical records.

According to a poll of over 15,000 doctors in the United States, around 42% said they were burnt out. Sixty-six percent of respondents proposed less bureaucratic chores, while 39 percent suggested lower working hours to reduce physician burnout. Furthermore, numerous physicians stated that more money and a more tolerable work schedule would alleviate the sensation of burnout.

Causes, signs and symptoms of physician burnout

Causes

Burnout is frequently induced by long periods of high stress, yet stress does not happen overnight. As a result, the specific cause of burnout differs from one person to the next. The medical industry is wide and includes many different professions, each with its own set of pressures. The main causes of burnout in medicine, on the other hand, are relatively similar and can be divided into three categories:

Work: Work conditions are one of the top-most causes for physician burnout. Other factors such as time pressure, dysfunctional work dynamics, corporate disorganization, overwhelming responsibilities such as emergency-room duties or chaotic or high-pressure environments can also lead to physician burnout.
Lifestyle: Lack of sleep, refusal to seek help when you are overworked, monotonous or repetitive job, and investing all your time and energy into it can lead to burnout.
Personality: Some people are born with some personality traits that make them prone to certain conditions. Burnout is more prone to strike people with perfectionist tendencies who are exceptionally high achievers and need to be in control of everything. People with a pessimistic outlook on life may find it difficult or impossible to delegate duties.

The concept of a suitable work-life balance is also important. You should be able to balance your personal and business lives.

Signs and symptoms

Physical symptoms: Increased fatigue, frequent illness, increased headaches, back pain or muscle aches, disrupted sleep — either sleeping too much or not sleeping enough, and changes in appetite.
Emotional symptoms: Feeling like a failure at your job or doubting your professional abilities, helpless about, trapped in or defeated by your work situation, feeling isolated and detached, unmotivated about the job, feeling less satisfied or accomplished in your work and unable to look at things positively or with hope.
Behavioral symptoms: Avoiding employment obligations, isolating oneself from family, friends, and coworkers, procrastination, aiming one’s rage at the people around them, turning to food, drugs, or alcohol as a coping method, skipping work, arriving late, or leaving early on a regular basis.

To avoid burnout, there should be a work-life balance, as mentioned earlier. For this, you need to delegate various tasks to suitable entities. Thus, physicians can entrust medical documentation requirements to a good medical transcription service provider and be relieved of tedious EHR documentation and management.

How Outsourcing Medical Transcription Can Lessen Physician Burnout

Easy transition to EHR: The shift to an EHR is one of the leading causes of stress and burnout among doctors. Doctors aren’t trained to fill out forms and paperwork; instead, they’re focused on providing the best possible care to their patients. EHRs provide clinicians with more detailed data on patients, which they may utilize to improve outcomes, but switching to a new system isn’t always easy. Medical transcribing services take the bother out of keeping track of patients’ notes, removing one roadblock to full EHR implementation. Doctors can just dictate notes into their EHR rather than point and click.
Saves time: Doctors are busy people who don’t like wasting time when they have a long list of patients to diagnose and cure. Spending half of their day typing up notes is a proven way to lower job satisfaction and trigger burnout symptoms. Outsourcing transcribing allows doctors to focus on what they do best, i.e. working with patients.
Good quality care: Medical transcribing demands a high level of skill, and accuracy is an absolute must. Taking notes on a daily basis can be tiring and doctors can make mistakes, but outsourcing transcription ensures that those errors do not make it into the final record. Quality transcription services begin with accurate transcription, identify any errors, omissions, or potential conflicts within each document. Careful attention to detail ensures that physicians are working with accurate data, helping them make better decisions for their patients. Doctors are more confident in their care when they have confidence in their notes. Maintaining that level of self-assurance can mean the difference between burnout and job happiness in the long run.
Helps keep up with changing regulations: Practices must stay abreast with the ever-changing reimbursement situation. Bundled payments are one example of this expanding practice. In addition, as more patients want improved pricing transparency, practitioners must pay attention to alternative payment mechanisms and the growing popularity of tiered and limited networks. In the face of increased rules, outsourcing can help practices stay competitive.
Better data security: A data breach can potentially cost millions of dollars, not to mention the damage to one’s reputation. While clinic personnel must be HIPAA-trained, they are unlikely to be data security experts. By outsourcing duties like transcription, practices can stay compliant while also ensuring that their records are protected using data security best practices.

Physicians are increasingly aware that they are exposed to workplace factors that increase their risk of burnout. Furthermore, it is expected that long-term exposure to work-related stress will lead to burnout. This, however, can be avoided by outsourcing some of your time-consuming tasks. If medical practices decide to hire medical transcription services, then they will be able to combat physician burnout to a great extent without compromising the quality of patient care.

Why Mental Health Transcription Services Have Greater Challenges

21-April-2022 Rajeev Rajagopal Medical Transcription Company

Mental Health

Mental health transcription is a critical component in the field of psychiatry, catering to the needs of psychiatrists, psychologists, and other mental health professionals. Mental health transcripts are highly sensitive and often presented in narrative form. Mental health therapy and counseling sessions are recorded and transcribed to track patients’ progress and develop personalized treatment plans. Due to the depth and complexity of these sessions, this transcription process presents unique challenges compared to that of other medical specialties. Therefore, it is important to hire mental health transcription service provided by experienced and trained medical transcription professionals who understand behavioral health transcription challenges and can address them effectively.

Specialized Expertise Important in Mental Health Transcription

Apart from medications and other treatments, mental health diseases also require therapy and counselling sessions to overcome any mental or emotional roadblocks. These sessions help to reduce stress and anxiety, and form a healthy mental state. Each of these sessions may take up to an hour or more, and are recorded and transcribed accurately.

Trained professionals with expertise in mental health and behavioral science are crucial in accurately documenting the intricacies of therapy sessions, contributing significantly to the overall well-being and progress of patients seeking mental health support. These experts follow a systematic process to transcribe various documents, notes, medical reports, and charts into precise and accurate medical records. Their familiarity with complex mental health terminology plays a key role in ensuring clarity and correctness in documentation.

Challenges in Mental Health Transcription

Maintaining confidentiality of mental health records: Mental health records are much more sensitive than any other medical records and they need to be shared and received with extra care. This helps to maintain the confidentiality of the mental health records. Strict data security measures should be implemented to avoid leakage of patient information, which could lead to patient embarrassment or worse if released. Transcriptionists should abide by these strict measures because they deal with the patient’s mental health history and the present status.
It is vital for all parties involved to be HIPAA-compliant and also follow all the federal regulations to protect the security, privacy, and confidentiality of the protected health information.
Large volume-narratives need to be transcribed: Unlike a regular patient, a mental health patient’s situation goes way beyond any symptoms. It involves changes of feelings and emotions over a span of days or weeks. The psychiatrist, psychologist or other mental health-related professionals conduct several sessions with the patient until he or she feels better. Each of these sessions can be more than an hour and will have some important information that helps to treat the patient. Transcribing these sessions can be overwhelming. Every detail that a patient reports to the doctor should be noted down because it will be helpful for the treatment of the patient.
Recordings vary from patient to patient: Mental health transcription is different from other medical specialty transcription. Since they deal with a patient’s mental health history and status, the clinical notes are often more varied, and commonly include longer narratives instead of standard medical terms or phrases. Specialties like cardiology or neurology use standard phrases or notes because the underlying conditions, surgeries etc. will be more or less the same for the patients. But in the case of patients with mental health issues, each patient will have a different mental state and the narratives of each patient will vary. This can be challenging for transcriptionists due to the broad spectrum of behavioral health transcription challenges involved.
Complexities in medical terminology: Medical terminology related to mental health can be highly complex. Therefore, it is important to ensure that the transcriptionist has an in-depth understanding of all the complex mental health terminology and insurance guidelines to generate error-free patient records.
Understanding slang words and jargon: In psychiatry, there may be less emphasis on standard medical terms and more emphasis on slang or specialized terms. These would be difficult for non-native English speakers to understand if the transcription is outsourced to an overseas company.
Background noise and overlapping speech: Group therapy sessions or multi-participant interactions often feature overlapping dialogues and background noise. Identifying speakers, capturing their words accurately, and filtering out unnecessary noise require advanced transcription tools and skills. Without clear audio or speaker identification, the transcription may fail to provide an accurate record of the session.
Maintaining compliance with legal requirements: Accurate mental health documentation is critical for medico-legal cases, insurance claims, and court proceedings. Failing to comply with the required standards can lead to legal issues, denied claims, or even harm a patient’s case. Transcriptionists must stay updated on the latest legal requirements and ensure meticulous documentation to meet compliance standards. Maintaining compliance with legal requirements in mental health transcription is vital for both legal protection and patient care.
Ensuring accuracy and precision: A single error in mental health records transcription can have significant consequences, from misdiagnosis to legal disputes. Transcriptionists must ensure exceptional attention to detail and double-check their work to ensure the final transcript is free from errors. Also, the transcripts are checked by editors and proof-readers to ensure accuracy and precision in psychiatric transcription, maintaining the highest level of documentation quality.

Mental Health Transcription

The above-mentioned are the challenges faced when transcribing mental health notes. However, a reliable medical transcription services company has professional transcriptionists trained in the specificities of mental health transcription. These services play a major role in accurate documentation. They provide error-free medical records, transcribe transparently, follow stringent safety measures, maintain quality standards, and are also HIPAA-compliant.

Get accurate and confidential documentation for your practice.

Partner with trusted MOS for efficient workflow and better patient care.

How to Create an Effective Psychiatric Progress Note

18-April-2022 MTS TEAM Psychiatry Transcription

Psychiatric Progress Note

The importance of psychiatric progress notes lies in their ability to provide accurate information on a patient’s health and treatment plan. Psychiatric progress notes are an essential part of the medical record and help identify the patient’s problem, determine appropriate treatment, and follow up the course of treatment to see if it is effective. Psychiatric progress notes are supposed to be accurate, succinct, and legible. They also need to cover all aspects of the patient’s condition, including diagnosis, symptoms, response to treatment, and any other pertinent information. A mental health transcription service helps to accurately document psychiatric progress notes.

The following are some essentials tips to create accurate progress notes:

Record the symptoms: Address your patient’s report on how their symptoms are responding to treatment in detail. This allows all parties involved in the evaluation to assess the efficiency of treatment alternatives. Be honest about any responses which indicate that the current treatment isn’t working, and make sure to address all elements of their symptoms as they progress through treatment. Physical and psychological symptoms may manifest at different times.
Content of therapy: This is a small review of what is covered during a personal assessment. You must document the client’s present mental health status, and it is helpful to express this from their perspective.
Therapeutic Interventions: This section includes the description of the precise treatment procedures that were discussed during your session in further depth. Based on the patient’s new symptoms, describe your approach and strategies for achieving goals.
Status of Mental Health: Every aspect of your patient’s current mental health is to be thoroughly and objectively included in this section. It has both existing and problematic features, as well as symptoms that aren’t present, in order to provide a framework for diagnosis. This can also involve observations of your client’s physical and verbal acts and reactions that point to circumstances they aren’t expressing.
Diagnosis: In this section, you can list out one or more specific diagnosis that the patient requires. This section will be updated as the treatment goes on.
Recommendations, instructions and treatment plan: The diagnosis, short-term goals, and treatment strategy will all be summarized in this portion of your psychiatric progress note. Your goals should include strict deadlines that help you create a treatment timetable, as well as notes about how far you’ve progressed toward your current objectives. It could also signal a lack of progress, necessitating changes to current deadlines. This note will conclude with a summary of the session’s duration.

In November 2020, new federal rules were implemented where healthcare providers must offer patients online access to their clinical notes (“open notes”). Access will not just be to lists of medications, appointment dates, and test results but to the very words written by clinicians. More than 52 million Americans now have access to their medical records through online health portals. According to surveys, patients’ experiences with reading their notes are overwhelmingly good, with one of the many benefits being a better understanding of their prescriptions. Mental health providers must strike a balance between transparency and respect for patient autonomy while maintaining clinical depth in their notes to comply with the new guidelines.

Here some more tips on generating accurate mental health progress notes:

Talk to your patient about open notes: Patients should be informed about the practice and the purpose of medical records. Advise them that reading their notes can assist them in remembering their care plan, appointments, and treatment reasons. Inform them that there’s a chance they’ll be disturbed by what they read, but that they can get continued assistance and clarifications during visits.
Write clearly and sensitively: Do not use too much medical jargon and acronyms, and don’t forget to focus on the details. Write as if both patient and another clinician are in the room and monitoring. Some common phrases such as “patient denies” or “patient refuses,” may be considered derogatory. Use phrases like “The patient stated that they do not use recreational drugs” or “The patient declined therapy.” If you utilize a specific diagnosis in your note, ensure that the patient understands it.
Be empathic and supportive: Write also about the patient’s pathology and its progress.
Ask for feedback: Encourage comments and remind visitors that any problems can be addressed during their visit.

Purpose of error-free psychiatry documentation

Having accurate psychiatry progress notes helps to keep track of clinical data for future reference. It also helps healthcare providers to communicate with each other and use the notes as a source of information and guidance. This is vital especially for writing consultation notes or discharge summaries. Error-free mental health notes are also useful for providing information to insurance companies and third parties that is adequate for billing and reimbursement; accurate notes also serve as a legal record in case of any medico legal issue. Therefore, documentation of any other significant issues related to mental health should be accurate and precise. Medical transcription outsourcing helps in generating accurate psychiatric progress notes. Mental health records are sensitive documents and these services ensure HIPAA compliance and follow all regulations so that the mental health records are kept safe.