5 EHR Systems Dermatology Practices Can Use. What Assistance Can A Dermatology Transcription Service Provide?

13-January-2022 Rajeev Rajagopal Medical Transcription

Dermatology Practices

As in all medical specialties, timely documentation and transcription is crucial in dermatology. Based on the recommendations from the Electronic Medical Records (EMR) Mandate, all healthcare providers are required to convert all medical charts into digital format. Dermatologists treat many skin conditions ranging from acne to skin cancer. They may have to perform a broad range of procedures on many patients. Many practices rely on EHR-integrated dermatology transcription services to handle their EHR documentation tasks.

EHRs streamline communication, increase charting efficiency, improve documentation accuracy, simplify administrative and financial tasks, and enhance physician and staff productivity. Advanced dermatology-specific EHR software come with templates and features that simplify the care delivery, documentation, and billing processes.

Let’s take a look at 5 best EHR software for dermatologists –

Nextech

nextech

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This dermatology EHR system is customizable for most practice’s workflows. Its medical and cosmetic templates are tailored to meet each provider’s unique charting preferences. It offers views of all relevant patient details, streamlining the encounter and documentation process. This software uses smart stamping and 3D anatomical models to pre-populate exams, assessments, treatment plans and billing codes, all with a single click. This HIPAA-compliant system can also improve productivity and time management with talk-to-text dictation and voice commands from within the EHR.

EMA Dermatology

ema dermatology

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This easy touch-based dermatology EMR solution can clearly understand practice patterns and eliminate the need for templates. Designed for use on the iPad, EMA software brings a new touch screen approach to cloud-based EMR systems. Based on the unique username, it can recognize each practice’s preferred methods and even suggest top diagnoses and treatments. It enables providers to run powerful analytics and studies for value-based medicine in the form of MACRA and MIPS regulations. Its key features such as Outcomes and Grand Rounds can help evaluate and create clinical data from the nationwide dermatology community and provide a quick snapshot of patient progress and common treatments for specific diagnoses. Being cloud-based, providers can use this EHR virtually wherever and whenever they want.

DrChrono

drchrono

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This advanced EHR system minimizes paperwork and errors by auto-populating patient information to clinical charts, procedures, and lab and radiology orders. The software comes with key features such as convenient e-prescribe medications, options to take HIPAA compliant photos of patient’s condition, and medical templates, making it an ideal platform for dermatologists. Its comprehensive dermatology medical forms are designed to meet the specific needs of the practice and its real time eligibility Insurance Check provide verification of payment.

Practice Fusion

practice fusion

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This custom-tailored EHR for dermatologists is well known for its overall performance, scalability, reliability, training, meaningful use, and support. This software makes charting a more natural and intuitive process with less clicking and typing, offering providers more time to focus on patients. This platform can customize each provider’s EHR workflow to suit their needs while maintaining a single administrator. Its specialty-specific customizable flowsheets allows providers to quickly track patient health data, identify gaps in chronic care, and view historic lab results during the encounter.

Kareo Clinical

kareo clinical

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Designed and managed by healthcare providers, this cloud-based EHR makes it easy for dermatologists to write notes and prescriptions, code encounters, and manage patients. This fully integrated, cloud-based EHR features a comprehensive dashboard, simple charting options, easy e-prescribing, convenient eLabs, electronic superbills, and integrated patient portal.

How Dermatology Transcription Service Providers Can Help?

Documenting patient histories, surgical therapies, microbiology and biopsies in the EHR can be complex. Dermatology has specialized terms not seen in other medical fields. To improve EHR documentation, dermatologists can rely on EHR-integrated dermatology transcription services. A reliable medical transcription company can ensure that all clinical data is captured correctly in the EHR system in a timely manner, so that it is readily available for review by all healthcare providers and physicians involved in the patient’s care.

Accuracy in transcription is crucial to record pertinent facts, findings, and observations regarding a patient’s health history, past and present illnesses, examinations, tests, treatments, and delivery of care. Experienced transcriptionists are also familiar with the medical terminologies specific to all dermatology subsets such as cosmetic dermatology, dermatopathology, immunodermatology, Mohs surgery, pediatric dermatology and dermatoepidemiology, as well as all dermatologic therapies and medications. By helping physicians manage tedious and difficult EHR data entry tasks, medical transcription service providers can maximize dermatology practice efficiency, ensure access to accurate and timely documentation, and support delivery of quality care.

So regardless of the EHR system you choose, make sure that the medical transcription service company you partner with is HIPAA compliant and can ensure error-free and timely clinical documentation.

How Medical Practices Can Embrace Telehealth With Medical Transcription Services

10-January-2022 MTS TEAM Medical Transcription

Telehealth

In today’s busy world, it is increasingly difficult for individuals to stay on schedule. Fortunately, many medical practices are turning to telemedicine to help ease the stress of a busy day. Telehealth is the delivery of health care services, diagnostic testing and clinical assessment through telecommunications technology. It can be used to connect patients to health specialists, provide continuing education for doctors, and connect people in rural areas with the necessary healthcare options. It is an ideal option for medical practices that are looking to cut costs and improve convenience by reducing travel time and increasing access. Telemedicine allows patients and doctors to connect remotely and discuss treatment options, test results, and other details. Treatment through telemedicine requires a substantial amount of documentation so that the patient can be properly monitored and the doctor can remain within legal and privacy requirements. The patients take part in video calls with their healthcare providers; the audio and video recordings created have to be transcribed into physical and digital files for reference and future use. With the help of a medical transcription service, the process of generating accurate medical records becomes faster, affordable, reliable and easier for everyone involved. Telemedicine requires a change from paper records to electronic medical records (EMRs). Once a medical transcriptionist converts an audio file into an electronic text file, they can upload their completed file into the correct EMR system, freeing up the doctor’s time.

Telemedicine Consultations and Their Transcription

Here are some of the ways in which telemedicine consultations are carried out, each of which involves audio or video recordings. Telehealth transcription services can help medical practices embrace these processes by providing timely transcripts of the recordings.

  • Telemonitoring: Telephones are an important part of tele monitoring system. The VA medical centers in San Francisco and Washington, D.C., have operated telephone pacemaker monitoring systems since 1962. This monitoring system acts like pacemakers that are designed to transmit at different frequencies and an electrocardiogram (ECG) can detect the difference. A device can be attached to a telephone and transmit ECG readings to a health clinic. This helps the physicians diagnose the patient without seeing him/her in person.
  • Telehealth with video: Telehealth is possible from anywhere using your browser. It is easy to use, requires no apps to be downloaded for patients or doctors, provides group call facility up to four participants, and ensures comfort and ease of use. Telehealth helps in creating digital documentation and the documents can be saved in PDF format, which can later be added to the patient’s file. The patient records can be related to medications, diagnoses, allergies and immunizations, lab tests and results, care plans and upcoming and past appointments. Since the outbreak of the pandemic, telehealth has become popular. This facility is useful for patients who are immunocompromised and patients who have difficulty accessing healthcare. There are also many situations in which patients have shown greater benefit from telehealth care than from face-to-face healthcare alone.
  • Teleradiology: The field of radiology is image oriented and images are transmitted electronically. Using telecommunication, radiographs or X-rays of broken bones and other internal ailments can be transmitted. Teleradiology process includes producing digital images or converting film images to a digital format along with patient information. This is compressed into transmissible size, transmitting and reconstituting them for evaluation and diagnosis. These images and patient information can be sent to radiologists’ work laptops so that they can view them from anywhere when they are on call.
  • Remote mental healthcare: Telemedicine is used to provide critical mental healthcare to remote patients. A successful program Rural Options for Development and Educational Opportunities Network (RODEO NET) uses this method to deliver mental health services in rural eastern Oregon. These telecommunications are transcribed accurately to be maintained as medical records.
  • Home health care: This facility allows patients to sit at home and receive patient care through a telephone or webcam. This system enables patients to communicate properly to the doctors about their symptoms and concerns. The doctors can get these conversations transcribed into medical records.
  • Prison healthcare: Telemedicine is useful for treating patients in prison. Prisons have very limited medical staff resources. Using telemedicine, physicians can provide proper care to prison patients and the recordings made can be transcribed into medical records. These can be transmitted between the prison and hospital facility.

Medical Transcription Services Have an Important Role to Play

Medical transcription services have an important role to play with regard to assisting medical practices in adopting telehealth.

  • Now that most practices have adopted EHRs, they can utilize EHR-integrated medical transcription for telemedicine. EHR systems can accommodate the transcribed digital files; most providers of transcription services automatically upload their completed transcripts into the correct part of the electronic health record system. This automated process is a huge time- and labor-saver for healthcare professionals.
  • Real-time medical transcription facilitates consistent record keeping. All the data related to patient interaction and record-keeping procedures can be maintained in the same electronic format to ensure a consistent practice. Electronic medical transcription allows the physician to store and locate all the electronic data in one place on the network.
  • Medical transcription providers can assist telemedicine practices in ensuring patient confidentiality and protection. Telemedicine is mostly internet based, and providers have to make sure that there is no breach of patient confidentiality or security. Typically, medical transcription is provided over a secure network and this security is ensured when receiving and sending files.

Medical practices have to deal with a lot of documentation. Doctors fill out charts, write prescriptions, and record patient data. Medical transcription companies help to keep this process as efficient and effortless as possible. Medical transcriptionists are professionally trained in effectively and accurately transcribing conversations between doctors and patients. They can also ensure that the information is properly aligned with legal and privacy requirements.

Medical transcriptionists ensure that the information fits on a computer screen. They also make sure that the text is easily searchable. In addition, they help eliminate miscommunication when converting audio files into text and ensure that everything is interpreted correctly and appropriate medical terms are used. Value-added medical transcription helps physicians focus more on the patients, and understand their actual concerns instead of having to wrap up the consultation quickly to document patient interactions.

With the advancement of internet technology and the ubiquity of mobile devices, it’s now possible to deliver health services via phone, email, chat, and video. These audio and video recordings can be transcribed into error-free medical reports with the assistance of medical transcription providers, and it also makes it easier for healthcare professionals to find what they need quickly in an electronic file. So, from the above-mentioned points, it is clear that telemedicine and medical transcription service have a significant role to play in the future of healthcare.

DAP vs SOAP Therapy Notes? What Are the Differences?

03-January-2022 Rajeev Rajagopal Medical Transcription

DAP vs SOAP Therapy

DAP vs SOAP Therapy Notes? What Are the Differences?

In today’s healthcare scenario, electronic health records (EHRs) have emerged as invaluable tools for healthcare professionals, significantly enhancing patient care and management. In behavioral health, the integration of EHRs with mental health transcription services presents several advantages, from enhanced provider collaboration, more effective medication and crisis management, to improved health information privacy and security, and more.

Meticulous and comprehensive documentation of mental health progress is of paramount importance in delivering optimal patient care. In this context, there are two prevalent methodologies for mental health documentation:

  • The SOAP (Subjective, Operative, Assessment, and Plan) method, and
  • The DAP (Data, Assessment, and Plan) approach

The American Psychological Association (APA) underscores the psychologist’s role in balancing diverse considerations to choose the most suitable record-keeping approach. Let’s look into the formats of SOAP and DAP notes and understand how they empower psychologists, therapists, and other healthcare practitioners.

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SOAP Therapy Notes

SOAP therapy notes are an essential part of the documentation process in the field of therapy and counseling. The SOAP acronym, which expands to Subjective, Objective, Assessment, and Plan, provides a structured format for therapists to record and organize information about their clients’ sessions. Let’s take a look at the role of SOAP therapy notes in more detail:

Subjective: The SOAP note’s subjective section captures the client’s subjective experiences, emotions, thoughts, and concerns as expressed during the therapy session. Therapists document the client’s verbal statements, descriptions of symptoms, and any relevant information they share. This section helps create a comprehensive picture of the client’s current state of mind and provides insight into their subjective experiences.

Objective: The objective section contains factual and observable information gathered by the therapist during the session. It includes the therapist’s observations, assessments, and measurements. This section may have a description of the client’s behavior, appearance, body language, and any significant non-verbal cues. The data provides an objective view of the client’s situation and helps to support the therapist’s assessments and treatment planning.

Assessment: The assessment section details the therapist’s professional analysis and evaluation of the client’s progress, mental health status, and treatment outcomes. It includes the therapist’s clinical impressions, diagnoses (if applicable), and any relevant assessments or tests conducted during the session. The assessment section helps the therapist monitor changes, identify patterns, and make informed decisions about the client’s ongoing treatment.

Plan: The plan section outlines the therapist’s proposed treatment plan and goals based on the information gathered during the session. It includes the strategies, interventions, techniques, or therapeutic modalities that the therapist plans to utilize in future sessions. The plan section may also include referrals to other professionals or community resources, if necessary. The plan serves as a roadmap for the therapist and helps ensure continuity of care and progress towards the client’s therapeutic goals.

SOAP therapy notes play a vital role in documenting, tracking, and evaluating therapy sessions. They facilitate effective communication and collaboration among therapists and other healthcare professionals involved in the client’s care. These notes provide a thorough record of the client’s treatment, which can be important for insurance purposes, legal requirements, or in case of audits or disputes. SOAP notes also support continuity of care by allowing therapists to track the client’s progress over time. This note format assists therapists in evaluating the efficacy of treatment interventions and making informed decisions about ongoing therapy. Based on this evaluation, therapists can seek supervision or consultation if needed.

DAP Therapy Notes

The DAP note aims to helping mental health professionals document and track the patient’s progress in an organized and efficient manner. This simple, comprehensive template is part of the official record and can be shared with others. If it includes Response, this note format would be written as DARP.

Data: In the data component, the provider has to document everything heard and observed in the session. This mostly comprises self-reported information but also includes important observations of the therapist. While the data will be mostly objective, the clinician may include some subjectivity. For example, if they may note that the client “appears agitated”. The question “What did I see?” is the gist of this section.

Assessment: The DAP note assessment section documents the clinician’s interpretation. Important questions to answer include: Is the client making an effort to resolve their issues? Are they making progress? What does the data mean – does it point to a particular diagnosis or issue to be addressed?

Plan: This portion comprises the plan for future treatment, including changes or new directions to the overall treatment plan. It could include both what the therapist wants the client to do next and what they want to accomplish as a therapist. This segment is not the entire treatment plan, but simply the goal to accomplish from one session to the next. It answers the question, what will I do next?

DAP therapy notes play a multifaceted role in the field of mental health and therapy. They are essential for documentation, assessment, treatment planning, communication, and legal compliance. These structured notes are invaluable tools that contribute to the overall effectiveness, accountability, and quality of mental health care.

Differences between SOAP and DAP Therapy Notes

Here is a comparison of the SOAP and DAP therapy note formats:

Aspect SOAP Therapy Notes DAP Therapy Notes
Structure Has four sections Comprises three sections
Subjective (S) Focuses on the client’s subjective experiences and perceptions, including emotions, thoughts, and concerns. Integrated into the Data section, with a broader scope that includes both subjective and objective information
Objective (O) Contains objective, observable, and measurable information such as vital signs, behaviors, and facts. Combined with the Data section in DAP notes.
Assessment (A) Involves the therapist’s clinical assessment of the client’s condition, diagnosis, and progress. Separately dedicated to assessing the client’s condition, progress, and other relevant factors.
Plan (P) Outlines the therapist’s plan for future sessions, including treatment goals, interventions, and recommendations. Offers a dedicated section for outlining the treatment plan, goals, and future actions.
Integration of Data Keeps subjective and objective data separate. Integrates both subjective and objective data in the Data section.
Focus on Observation Clearly separates subjective and objective observations. Combines subjective and objective observations for a holistic view.
Usage Historically more commonly used in medical settings. Gained popularity in behavioral health and therapy settings.
Emphasis on Diagnosis Significant emphasis on diagnosis and clinical assessment Focuses on a broader assessment that includes the client’s experience and progress.
Flexibility May need modification to fit therapy and counseling Designed specifically for therapy and counseling.
Transition of Care May require translation or adaptation when transitioning between medical and therapeutic care. Supports smoother transitions in mental health and therapy settings.

Both SOAP and DAP notes serve the essential purpose of documenting client interactions in a structured manner. However, in contrast to the medical field, distinguishing between objective and subjective aspects in mental healthcare can be challenging. DAP notes offer a solution by eliminating the need to categorize data as subjective or objective; instead, all relevant information can seamlessly come together in the data section. This is precisely why many mental health practitioners prefer DAP notes.

How to write Good DAP Notes

Structured note taking is important to save time and include all the information needed to make assessments and treatment plans. Here are some tips for writing quality DAP notes:

  • Use the best documentation tools built with DAP note structures
  • Keep the notes simple: include only relevant information collected in the session
  • Make sure the information can help build a strategy for the patient
  • Ensure accuracy and make sure the notes are easy to follow
  • When including the patient’s words, use quotation marks
  • Review the dates and times of occurrences, and spellings
  • Use standard procedures to make corrections

EHRs enable healthcare professionals to collaborate seamlessly, crafting individualized and holistic care plans for every patient. Regardless of their preferred note-taking format, the availability of competent medical transcription company is crucial to ensure precise and timely documentation within the EHR system.

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Our Top 10 Blog Posts Of The Year 2021

30-December-2021 MTS TEAM Healthcare News

Top 10 Blog

As 2022 is here, it’s time to take a look at our top informative blog posts of last year. Being a medical transcription company with years of experience in the industry, we’ve been serving diverse medical specialties including physical therapy, pathology, dentistry, and more. We make sure that all our blogs are unique and provide insights on medical transcription-related news, updates, and events.

For the year 2021, our blog session covered topics such as writing mental health progress notes, best medical transcription software, documentation tips in occupational therapy, and more.

Check out Our Top 10 Blog Posts for 2021

1. Importance of Interface between Practice EMR and Pathology LIS

emr

Fast processing of laboratory test results is essential to quickly and accurately diagnose and treat patients. According to experts, establishing an interface between practice electronic medical record (EMR) systems and pathology laboratories can improve workflow and efficiency in both settings. This implies the efficient deployment of laboratory Information System-Electronic Medical Record (LIS-EMR) electronic interfaces. This blog discusses the relevance of interface between practice EMR and pathology LIS.

2. What Is The Difference Between EMR And EHR

ehr

Electronic medical record (EMR) and electronic health record (EHR) help store patient data. Even though EHR and EMR have common features, they mean different things and serve different purposes. EMR has been defined as a digital version of the paper charts in clinician offices, clinics, and hospitals and EHRs contain information from all the clinicians involved in a patient’s care, and all authorized clinicians involved in a patient’s care can access the information to provide care to that patient. This blog discusses the differences between these two types of medical software.

3. How To Write Good Mental Health Progress Notes

mental health

Mental health progress notes refer to key notes that psychologists, therapists, clinical counselors, psychiatrists, and other practitioners make at each session about the patient’s clinical status. These notes may include important issues or concerns associated with the patient’s treatment over the course of care. Read the blog for some useful tips to write good mental health progress notes.

4. Best Approaches for Documenting Allergies in the Electronic Health Record

documenting allergies

Accurate and timely documentation of allergies in electronic health records (EHRs) is critical for practices to be better prepared for adverse events and ensure proper care.It is important to document a complete and accurate allergy history for each patient. This blog is about the best approaches for documenting allergies in the Electronic Health Record.

5. HIPAA Confidentiality Regulations That Apply To Medical Transcription

hipaa

Any covered entities such as health plans, health care clearinghouses, and health care providers or business associates that handle protected health information (PHI) are required to be HIPAA-compliant. This blog highlights all the HIPAA regulations that apply to medical transcription and companies providing medical transcription services.

6. Top 5 Free Medical Transcription Software

medical transcription software

It is important for healthcare practices to create accurate transcripts of voice recorded treatment notes dictated by physicians, nurses, and other healthcare providers. These transcripts are necessary for physicians to make treatment decisions and plan care. Advanced medical transcription software is available now to reduce documentation time. This blog is about the best free medical transcription software in the market.

7. What Are The Documentation Requirements For ED Reports?

ed reports

Accurate and thorough patient chart information is important in Emergency departments (ED) and any other specialties for further communication between healthcare professionals involved in patient care in a hospital and also upon discharge. Our blog discusses the documentation requirements for ED reports.

8. How To Use Medical Dictation Software Effectively

medical dictation software

Speech-to-text medical dictation software helps practices to eliminate typing, save time on clinical notes, improve productivity, and access the documents from anywhere. Using this voice recognition software, providers can easily record and document interactions with patients on their mobile, laptop or workstation. This blog provides tips to use medical dictation software effectively. Some of the top medical dictation software include Mobius Scribe, Dragon Medical One, Amazon Transcribe Medical, WebChart MD, and Express Scribe.

9. Top Tips for Effective Documentation in Occupational Therapy

occupational therapy

Just like any other medical specialty, in occupational therapy (OT) too, providers must ensure proper documentation of their services. Proper EHR documentation is important to enhance patient care, streamline office workflow, reduce health records errors, improve document management speed and efficiency, and get appropriate reimbursement. This blog discusses the top tips for effective documentation in occupational therapy.

10. How Medical Transcription has Evolved Through the Years

medical transcription

Medical transcription services have come a long way since their inception. In this 21st century, medical transcriptionists play a key role in the healthcare system by supporting physicians in the creation of electronic health records (EHRs). This blog discusses how medical transcription has evolved through the years. Medical transcription outsourcing is of great support for physicians in editing and proofreading the transcribed documents.

Hope you enjoyed our blogs last year! Looking forward to serving you again in 2022!

Stay tuned!

How Medical Practices Can Minimize Patient Wait Times

27-December-2021 Julie Clements Medical Transcription

Patient Wait

The Electronic Health Record was introduced with the objective of transitioning into a unified healthcare system to provide better quality patient care and also ensure the safety of patient data. Although the EHR ensures better healthcare by improving all aspects of patient care, including safety, effectiveness, communication, timeliness, efficiency etc, it has some drawbacks. Earlier, medical transcription services allowed physicians to have enough face time with their patients but the EHR has burdened physicians with medical documentation and they are forced to spent most of their time on documentation.

This reduces the face-to-face time with patients and affects the quality of patient care provided. It also leads to long wait times for physician appointments, which is a major reason for patient dissatisfaction.

In a study published in cardiovascularbusiness.com, 30 percent surveyed patients reported they’ve walked out of an appointment due to a long wait, while 20 percent said they’ve changed doctors because of wait times. Medical practices that fail to address wait time issues end up losing 48 percent of patients a year.

In a search report by Software Advice, two separate studies were conducted to understand the problem of long wait times:

  • In 2017,a physician survey was conducted to understand the factors that contribute to long wait times and how practices are handling them.
  • In 2020, a patient survey was conducted to understand the consequences of long wait times and how practices can reduce patient frustration.

    The findings of the research are as follows:

    • Majority of the physicians surveyed stated that very “often” their patients experience wait times longer than 20 minutes; and 61 percent of physicians have heard negative feedback from their patients regarding wait times.
    • 63 percent of physicians believe wait times make “no impact” or “minimal impact” on their ability to retain patients whereas 24 percent of patients said that they changed doctors because of long wait times.
    • 64 percent of physicians say patient arrival times, like patients arriving later than their scheduled appointment time, are usually the major reason for long wait times.
    • 83 percent of patients say being told in advance what the wait time will be could help to reduce frustration.

    Scheduling the right number of patients to cover costs but not trying to overbook is a balancing act for physicians. No-show patients cost around $200 per unused time slot, and the average no-show rate for most U.S. practices is around 20 percent, and this leads to loss of revenue. So, to avoid the chances of financial loss, physicians try to schedule maximum patients. But it is important to ensure wait times are not too long.

    Many physicians are unaware of the fact that lengthy wait times make an impact on their practice’s ability to retain patients. But according to the research, nearly a quarter of patients say they’ve literally walked out of a waiting room, choosing to reschedule or even cancel rather than wait any longer.24 percent of patients have discouraged their friends and family from seeing a certain doctor, and 14 percent have left negative comments on online review sites specifically because of practice wait times. All of these can result in missed appointments and loss of revenue.

    Research was further conducted to better understand the root cause for long wait times and the physicians stated that there are two main causes for long wait time:

    • patients arriving later than their scheduled appointment time, and ( 64 percent)
    • unexpected patient issues ( 61 percent )

    The following are some steps physicians can take to avoid patient-related delays:

    • Use software to send multiple appointment reminders. These reminders can be automated so that it can be sent via text message, email or phone call.
    • Set up a late arrival policy so that patients receive warning letters the first three times if they’re more than five minutes late.
    • Find out whether you will need to spend more time than usual on a particular visit. Ask patients to complete paperwork ahead of their visit to determine whether their symptoms need additional attention.

    To monitor patient wait times, physicians can follow these practices:

    • Invest in tracking technology: There are many patient scheduling and tracking vendors that can automate timers and generate reports for you.
    • Run a patient survey: Note down about wait times and collect other kinds of helpful practice management feedback.
    • Recruit volunteers: Volunteers can take detailed notes about the average visit length at your practice to identify bottlenecks without burdening your staff.

    Profitability and reputation are two prime elements for medical practices, and long patient wait times create a negative impression. All the above strategies help to reduce long patient waits. To make the patient consultation process more efficient, physicians can rely on medical transcription companies and avoid the burden of medical documentation.

What Are The Advantages Of Using A Pediatric-Specific EHR?

23-December-2021 Rajeev Rajagopal EHR Transcription

Pediatric-Specific EHR

Electronic health records (EHRs) have improved many elements of medical practice. Supported by medical transcription services, the software provides physicians with comprehensive information about a patient’s health status. Specialist practices need specialty-specific EHRs. A specialty-specific system can save time and money, improve productivity and allow physicians to spend more time on patient care.

Why Pediatric Offices Need EHRs with Special Features and Functions

Pediatricians care for a very special group of patients whom they love. They treat children with acute illness, congenital anomalies, chronic illness, seizure disorders, and trauma, providing patient-centered care for infants, children, and adolescents.

Pediatricians are also expected to provide screening services for a wide variety of disorders and have special expertise in areas like preventive oral health, mental health, and hearing and vision screening services. Other key issues pediatric practices may need to handle include vaccine inventory management, time constraints when seeing patients, maintaining patient compliance with the AAP’s recommended screening and assessment schedule and optimizing practice revenue.

A fully integrated EHR that includes medical billing, practice management, and integrates with pharmacy, labs, radiology is designed to enhance ease, speed, accuracy, and transparency of workflow and documentation in medical practices.

However, studies on physicians’ perceptions of EHRs report that pediatricians find EHRs stressful to manage.

A 2019 study on EHR use in pediatric practices reported that though the adoption of EHRs has increased, more than 80% of pediatricians are working with EHRs that lack optimal functionality and 41% of pediatricians are not using EHRs with even basic functionality. The researchers noted that EHRs lacking pediatric functionality affect patients’ health through increased medical errors, missed diagnoses, lack of adherence to guidelines, and reduced availability of child-specific information.

A dedicated pediatric EHR is essential to provide high-quality care for children and help pediatricians efficiently manage everyday activities.

Benefits of Pediatric EHR Platforms

Having an EHR system that is adaptable to the needs of pediatricians and their patients is important to save time, money and provide better care outcomes. A pediatric-specific EHR system is fully featured to tackle many issues that providers face:

  • Ability to update sibling history and create multiple sibling charts: Updating family history is important in pediatric care. Family health history can identify people with a higher risk of contracting common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and type 2 diabetes. With a pediatric EHR, updating history for all siblings is possible with just a few clicks. Likewise, if siblings visit on the same day, the system will allows the physician to create additional charts while charting one for the first patient. The ability to record and charge multiple sibling charts can increase reimbursement while saving time.
  • Vaccine-related functionalities: Not having an efficient system for tracking vaccine administration and inventory can be a major concern in pediatric practices. Child immunizations have a complex schedule. The vaccination record is required at multiple points in a child’s life, during education and up to adulthood. An efficient pediatric EHR would allow the physician to easily update the vaccination component and display in a way that can be shared with families and the educational system. Accurate records are also essential to submit vaccine information to state immunization registries. Further, a pediatric EHR would allow efficient management of vaccine supplies including tracking expiry dates and projecting future requirements, to optimize cash flow.
  • Tracking growth: Pediatric EHR software includes growth charts from the National Center for Health Statistics to track children’s growth. When assessing progress, the appropriate growth chart can be attached to the patient’s record.
  • Medication management: Variables such as weight and age are key considerations when writing prescriptions for pediatric patients. Pediatric EHRs should be featured to automatically provide the correct dosing amount based on these factors. It must also include alerts for patient allergies and drug interactions.
  • Confidentiality for adolescent patients: Adolescents are more likely to see a provider and return for follow-up if they are ensured that their information will be kept confidential. To optimize care for adolescent patients, quality pediatric EHRs are designed to address the confidential needs of these patients. The systems would make it easy to turn on privacy settings when the patient reaches the age of consent, which varies among states.
  • Advanced charting features: Child healthcare providers may also document adolescent mental health, reproductive health, and substance abuse, and share this information with other providers. A pediatric-specific EHR that has preloaded templates for all types of sick visits, would allow the physician to easily understand what to evaluate, so that they can provide an assessment, and chart the visit quickly.

EHR documentation methods have evolved greatly with efforts to improve delivery of care and ease the clinical burden. While speech recognition systems and EHR scribe tools allow physicians to document in real time, enhance efficiency, and lessen documentation tasks, error rates are a concern. However, a study published in the Journal of Informatics in Health and Biomedicine in 2020 showed that a digital scribe cannot replace a trained and certified human scribe.

Likewise, using a pediatric-specific EHR along with pediatric transcription services can help physicians make the most of the system. U.S. based medical transcription companies have experts who are well-versed in the procedures, treatments, medical terminology and jargon pertaining to different pediatric conditions can provide accurate and timely EHR-integrated documentation of history and physical exams, laboratory tests, diagnoses, operative procedures, discharge summaries.

What Are The Serious Errors That Can Occur In Medical Transcription?

20-December-2021 MTS TEAM Medical Transcription

Medical Transcription

Complete and accurate medical records ensure that patients receive the right care at the right time. Accurate records provide all relevant healthcare professionals with the information needed for decision making. In addition to supporting billing decisions and ensuring physicians are correctly reimbursed, proper record-keeping offers protection from lawsuits. Medical transcription services are essential for producing accurate patient records, as they meticulously convert physician dictations into precise text format. In fact, close attention is crucial to avoid errors that that can prove costly for both physicians and patients. Let’s take a look at the serious errors that can occur in medical transcripts.

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Serious Medical Transcription Errors to Watch Out For

Entering wrong information: Entering an incorrect value is one of the most common errors. This includes a wrong dosage, measurement, wrong dosage, measurement, patient detail, or medical terms. For example:

  • A medication dosage entered as “10mg” instead of “100mg”
  • Typing “hypertension” instead of “hypotension or “affect” instead of “effect”
  • Entering the wrong date of birth or medical history detail
  • Errors when converting between different measurement units (e.g., milligrams to grams)
  • Misplacing decimal points or incorrect use of commas in large numbers can alter the intended meaning of the data.

Such errors typically occur due to the transcriptionist mishearing dictation, making typos, or confusing similar sounding words. Physicians may also mumble, talk too fast, or use unclear pronunciation when dictating. Wrong data entry can potentially have significant consequences for patient care.

Patient ID mistakes: Every patient is assigned an identification number. Accurate identification of patients is crucial for patients who are non-communicative or are confused, patients or residents who require a special diet, to label containers used for blood and other specimens, and so on. Wrong patient identification hinder patient safety, cause detrimental healthcare outcomes, create opportunities for medical identity theft, and lead to patient data integrity failure, according to Patient Safety & Quality Healthcare (PSQH) article.

Some transcription platforms add names automatically, but others require it to be manually entered. To avoid an error, the medical transcriptionist should confirm that the name on the report is the same as what’s dictated. If it is absent, the patient’s name should entered correctly.

Omission in dictation/missing parts: Omission of important dictated words is another serious mistake. All words in the audio recording should be typed in, with special attention to important words relating to symptoms, diagnosis, and the treatment plan. To avoid omitting important words in the physician’s dictated report, an experienced transcriptionist will focus on accuracy and not speed. Phrases or words that are difficult to understand or not clear should be tagged and not omitted.

Confusion in medical terminology: Medical terminology includes confusing terms, abbreviations and variations. Medical transcriptionists, especially those who are new to the job, must be careful not to confuse medical terms. Misuse of medical terminology usually occurs with words that sound similar. Some examples include sac/sack; perfusion/profusion; cord/chord; BNP (brain natriuretic peptide)/BMP (basic metabolic panel); pharynx/phalanx; dysphagia/dysphasia. Experienced medical transcriptionists are knowledgeable about medical terminology and can identify medical terms, abbreviations, and phrases in dictated reports.

Wrong verb use and spelling mistakes: Back formation involves creating a new word by altering an existing word, usually a noun. Back formations are usually verbs but may appear as adjectives or adverbs. While back formations and false verbs are common in general communication but should be avoided in medical records. The Association for Healthcare Documentation Integrity (AHDI) gives examples of back formations that are considered unacceptable as: dehiscence-to dehisce; torsion-to torse; diuretics-to diurese.

Misspelled words: Spelling mistakes can cause confusion, impacting care with serious consequences. Words often misspelled include: abscess, adolescence, hemorrhoid, humerus, syncope, and syphilis. New terms, medications, equipment, or instruments may end up being spelt incorrectly since there are no reliable resources to verify them. Electronic spell checkers can be useful to correct spelling errors, but unfamiliar and new words should be flagged for verification.

Transcription reports with one or more critical errors or three or more major errors are considered unacceptable and rejected. Responsible medical transcriptionists are focused on provided completed files that are 99% accurate.

A medical transcriptionist should also refrain from editing a physician’s report if it changes the information, removes important details, or alters the original creator’s style. To promote clarity in communication, the Association for Health Documentation Integrity (AHDI) recommends editing as acceptable for the following:

  • Grammar, punctuation, spelling, and similar dictation errors
  • Slang words and phrases, incorrect terms, incomplete phrases
  • English or medical inconsistencies
  • Inaccurate phrasing of laboratory data

Errors in medication order transcription and verification can be serious. One study highlighted issues like omissions, inadvertent cancellations, duplications, and dose transcription errors, such as reversing doses or mischarting administration times (e.g., every 6 hours instead of every 8). The risks are heightened for chronically hospitalized patients undergoing multiple therapies, increasing the likelihood of medical errors throughout the medication process.

Maintaining specialty standards in reports is also essential. For example, oncology transcriptionists must be familiar with terminology related to red blood cell disorders, including terms for red cell morphology like spherocytes, anisocytosis, Howell-Jolly bodies, acanthocytes, megalocytes, stomatocytes, drepanocytes, and Rouleaux.

“Historically, care providers have relied upon the ability to dictate the details of a health encounter and have that “story” documented either by a transcriptionist or speech recognition technology (SRT) and an editor. As healthcare delivery moves toward a nationwide health information exchange network via electronic health record (EHR) systems, the ability to preserve the full story of patient’s health will be a critical consideration”, note the AHDI.

Ultimately, partnership between physician and documentation specialists including a reliable medical transcription company are key for capturing healthcare encounters and ensuring they are documented and formatted in a way that promotes clinical clarity and coordinated care.

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What Are The Benefits Of Electronic Exchange Of Patient Information?

16-December-2021 Julie Clements EHR Transcription

Electronic Exchange

Office-based physician adoption has more than doubled since 2008. EHR/EMR adoption rates were around 89% in 2020, according to SelectHub. EHRs offer many benefits over paper records, especially improved efficiency and speed, and the opportunity to provide quality patient care. Medical transcription service providers help physicians better manage electronic patient records. However, reports say that despite the prevalence of secure electronic data transfer, paper records are still widely used and shared, which affects care and also lead to reimbursement issues.

The Office of the National Coordinator for Health Information Technology (ONC) notes that a lot of medical information is stored on paper and shared between providers by mail or fax or carried to appointments by patients themselves. Paper-based data exchange on the payer side impacts care transition efficacy, delays treatment, and causes denials or payment reduction, ultimately affecting patient outcomes. Providers and payers need to move to electronic exchange of patient data to overcome healthcare data related challenges and delays in care.

What is Electronic Health Information Exchange (HIE)?

Patients often see multiple providers in different facilities using different EHR systems. To provide appropriate care, every physician treating the patient needs to have access to all of the patient’s medical history, and be able to view the patient’s electronic record with recent lab tests, diagnoses, allergies and prescriptions. HIE allows for this.

HIE is the secure and seamless electronic transmission of patient data among authorized healthcare providers and organizations. Electronic exchange of clinical information allows physicians, nurses, pharmacists, other health care providers, and patients to access and securely share a patient’s vital medical information electronically, which improves the speed, quality, safety, coordination, and cost of patient care (ONC).The COVID-19 pandemic increased the use of telemedicine visits, further highlighting the importance of electronic exchange of patient data among providers and payers.

Benefits of HIE

The three main types of health information exchange currently in use are:

  • Directed Exchange – ability to send and receive secure information such as laboratory orders and results, patient referrals, or discharge summaries electronically between care providers to support coordinated care
  • Query-based Exchange – ability for providers to find and/or request information on a patient from other providers, often used for emergency/unplanned care
  • Consumer Mediated Exchange – ability for patients to aggregate and control the use of their health information among providers, allowing them to correct inaccurate demographic, medical, or billing information, and track and monitor their own health.

HIE offers many benefits:

  • Reduces risk of medical errors and improves patient safety: If communication and information does not flow freely among healthcare providers, it can lead to medical errors. The EHR can have incorrect information if it is not updated immediately when new information, such as test results come in. This can lead providers to revert to paper paper-based document formats like fax for records exchange, leading to failures and delays (www.fortherecord.com). Electronic health information exchange improves patient safety by making the right information about the right patient available at the right time. HIE improves medication information processing, lab information processing, improved and radiology information processing It improves communication among providers, between patients and providers, and also allows for better public health information processing.
  • Increases provider efficiency by eliminating unnecessary paperwork and handling: HIE reduces costs and promotes better use of time for healthcare organizations and patients by doing away with paperwork. Clinicians can access health information needed for prescribing decisions, timely and reliable delivery of test results, and coordination of medical orders more easily, which in turn, improves focus on the patient.
  • Improves the quality of healthcare: By making critical patient information available at the point of care, HIE improves the quality of care. Relias Media references a new study which suggested that since a single EHR may not be a complete source of relevant clinical information, including standards-based data from a health information exchange can improve quality of care. When the physician sends a query to HIE, the data from the HIE comes directly into the patient chart, providing a clear picture of all the diagnoses of the patient, all the procedures the patient had, and all the lab results and allergies. Appropriate, timely sharing of vital patient information promotes better patient care, avoids readmissions, prevents medication errors, improves diagnosis and decreases duplicate testing.
  • Enables better patient engagement: Consumers are better informed about their own personal health information, which enables electronic patient engagement. HIE provides patients with an electronic copy of their all their medical information which they can share with multiple healthcare providers. HIEs are designed to combine and distribute health data from multiple sources directly to patients in a standardized format. This improves patient-provider communication and patient satisfaction.
  • Improves research: By providing data aggregation across multiple medical organizations, HIEs also support research to improve health care. While EHR data is also used for research, multiple systems need to be accessed to capture all relevant clinical data accurately. As they connect different EHRs in a community, HIEs provide comprehensive information and foster research.
  • Improves public health reporting and tracking: Effective community-based interventions need reliable data that can be shared with many organizations. EHR data compiled in HIEs can be used for disease surveillance, providing communitywide alerts, and to obtain demographic information for analysis.

Digitizing patient information and sharing it through HIEs is essential for patient safety and provider efficiency. Cloud computing and block chain are specifically designed to support sharing information, though organizations need to factor in security and compliance with regulations like HIPAA when using these technologies.

Information sharing in the health domain is a complex and challenging process. Incomplete or inaccurate in EHRs can disrupt the benefits of HIEs. Outsourcing medical transcription can ensure accurate, up-to-date and complete data in EHRs and support the goals of electronic health information exchange. From emergency room transcription to transcription for specialties like cardiology, pain management and behavioural medicine, an experienced medical transcription company can provide accurate and timely EHR documentation to support health information exchanges.

10 Useful Proofreading Strategies A Medical Transcription Company Employs

13-December-2021 Rajeev Rajagopal Medical Transcription Company

Proofreading Strategies a Medical Transcription Company Employs

To maintain high quality, compliant medical documentation, communicate efficiently with other healthcare providers and deliver proper care, physicians need to convert their dictated notes into accurate medical records. medical transcription services play a critical role in this context, transforming physician-dictated audio content into precise, written notes for integration into electronic health records (EHRs). How do medical transcriptionists ensure high accuracy and clarity in transcribed documents? They do so by carefully proofreading the medical documents before they are returned to the physician.

Before we discuss proofreading strategies in medical transcription, let’s take a look at common mistakes found in medical documents.

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Common Medical Transcription Errors that Proofreading can Identify

Mistakes in medical records can harm patients, leading to adverse events or even death. Inaccuracies may prompt incorrect decisions or treatments by physicians, compromising patient safety. Common errors found in medical records are:

  • Omission of dictated words due to fast typing
  • Choosing the wrong words; due to audio issues, words may be selected wrongly.
  • Misspelled words
  • Typographical errors that may occur due to fast typing.
  • Grammatical errors
  • Punctuation errors when commas, semicolons, hyphens, dashes or quotation marks are used incorrectly, and this may change the meaning of sentences.
  • Homonyms are sound-alike words and the correct word should be used to get the appropriate meaning that is consistent with the doctor’s dictation. Errors related to homonyms may occur in both English language and medical terminology.

Proofreading transcribed medical documents helps identify such errors, inconsistencies, and omissions. Now, let’s take a look at some key techniques that professionals use to enhance the medical transcript proofreading process:

Key Proofreading Strategies for Medical Transcription

  1. Use a printout: Proofreading on the screen can sometimes be a challenge. Using a printout of the report is often much easier than reading on the screen.

  2. Concentrate: To spot errors effectively, experts maintain a high level of concentration. They proofread medical records in a distraction-free environment by putting away their phone, turning off the television, and staying clear of any other devices that might cause interruptions.

  3. Read aloud: Reading the transcribed document aloud can help identify errors that may be overlooked when reading silently. Experienced transcriptionists focus on sentence structure, grammar, punctuation, and the overall flow of the text. Reading aloud can also help identify missing or incorrect words.

  4. Read it backwards: Usually, when we create medical records, we tend to ignore or become blind to our own mistakes. This is because the brain automatically corrects errors, making it challenging for individuals to spot them. To overcome this tendency, professional transcriptions read the medical record backward. This unconventional approach may help identify mistakes that might be missed during a standard, forward reading.

  5. Use reference materials: Teams in medical transcription companies will keep medical reference materials handy, such as medical dictionaries, drug references, and style guides. These resources can help verify medical terms, drug names, abbreviations, and formatting conventions. They cross-reference the transcribed text with these resources to ensure accuracy and consistency.

  6. Keep track of all medical mistakes: Medical transcriptionists also keep track of all the mistakes that commonly occur in their work. Categorizing and reviewing these errors helps avoid repeating them.

  7. Check spellings and homonyms: Double-checking the spelling of medical terms, drug names, and specialized vocabulary is an important proofreading strategy. Many medical terms can sound similar but have different spellings and meanings. Reliable transcriptionists pay special attention to homonyms (words that sound alike but have different meanings) and ensure that the correct word is used in context. For e.g., consider these sentences with words ‘bare’ and ‘bear’:
    • The patient’s skin was left bare during the examination.
    • The patient has difficulty trying to bear weight on the injured leg.

    Misinterpreting or misspelling homonyms can lead to significant errors in medical transcripts. While AI-powered tools can correct basic language, grammar, style, spelling errors, and even common homonym errors, they might not work if the context is ambiguous. That’s where the human proofreading skills become significant.

  8. Verify numbers and measurements: Experts pay special attention to numbers, measurements, and data in the transcribed document. Stating the correct figure and value in medical reports is critical. A minor variation in figures like the dosage of medicine or lab reports value can impact patient safety, and even be life-threatening. By checking for accuracy, decimal placement, and consistency, they ensure that units of measurement are correctly transcribed and match the appropriate medical context.

  9. Check punctuation and formatting: Professionals will review punctuation, capitalization, and formatting. They will ensure that medical abbreviations and acronyms are correctly punctuated and aligned with established guidelines, and parentheses, brackets, commas, and hyphens provide clarity and accuracy.

  10. Get feedback: Finally, medical transcriptionists will collaborate with others in their team and supervisors to get feedback and second opinions. A fresh set of eyes can often catch errors that may have been overlooked during self-proofreading.

    11. Check Out Our Infographic:

    Proofreading Strategies a Medical Transcription Company Employs

    Proofreading is a critical step in medical transcription that ensures accuracy and enhances patient safety. By employing these techniques, experienced transcriptionists improve the quality and reliability of transcribed medical documents. That’s why most medical practices choose to outsource their documentation tasks to a reliable US based medical transcription company. Leading companies have stringent quality checks in place to ensure accurate transcripts that meet specific instructions or guidelines provided by the healthcare professionals or organizations. Their team also stays updated with the latest medical terminology, guidelines, and industry best practices, which enhances their knowledge and skills in medical transcription and improves the quality of the documentation.

    With years of experience in the industry, we deliver accurate and timely transcription for all specialties.

    Contact us to discuss your requirements!

When & How To Document Injuries

06-December-2021 Julie Clements Medical Transcription Company

injuries

Accurate and proper medical documentation promotes patient safety and patient care. Just like documenting any disease or health condition, proper documentation of injuries is also important. When a patient gets injured from an accident or fall, it needs to be accurately documented with the help of a medical transcription company. It allows healthcare providers to monitor what has been done, provide better care, and this also minimizes the chances of patients returning to the hospital.

Accurate and proper documentation of injuries facilitates better patient care, reduces errors and keeps providers informed about a patient’s condition. It also helps to protect the doctors from any legal issues. The following are some features of effective injury documentation.

  • Provides access to factual, consistent, and accurate input
  • Updates the information after any recordable event
  • Ensures all information is current
  • Makes sure that all entries are legible and signed
  • Eliminates meaningless jargon, phrases or abbreviations that aren’t commonly understood

Poor Injury Documentation

There are many factors that can contribute to poor injury documentation. Anything that hinders the recording of patient information or poor communication between healthcare professionals can lead to poor documentation of injuries. Poor record keeping involves:

  • Incorrect entries
  • Spelling mistakes
  • Lack of clarity in entering data
  • Copying and pasting
  • Missing data
  • Failing to correct incorrect data in a timely manner
  • Use of incompetent service provider for medical documentation who does not understand medical jargon.

Recommendations for Proper Injury Documentation

The following are some of the tips to ensure clear and accurate injury documentation.

  • Always remember that whoever is reviewing the medical record may not have the depth of knowledge of the person who made the entry
  • Ensure that all healthcare providers understand the patient’s limitations
  • Make sure to record the current status and condition of the patient in the EHR
  • Confirm that the EHR states an objective story of the patient
  • The entries should reflect the level of care the patient is receiving
  • Record how and why a patient’s health is improving
  • Make sure that all entries are understandable and coded properly
  • The documentation should include patient and family directions
  • Make certain that all entries comply with regulatory, licensure and quality standards
  • If you are using a transcription facility, then ensure that they are US-based services who understand the context and can transcribe the medical jargon.

How to Take Daily Session Notes for Injuries and When It Should Be Complete

Daily session notes help to record all the services that you provide to the patient. Since it is recorded on a daily basis, it allows healthcare professionals to go through these session notes and plan for ongoing care. Consistent and accurate documentation serves as evidence about the assessment of the treatment and progress of service for a patient. This document shows the communication between healthcare providers. This helps those who receive documentation to be aware of any provider, client or family involvement in the daily session. It can also serve as required evidence for insurance companies to ensure you are properly reimbursed for the services rendered.

Some advantages of daily session notes:

  • Act as a legal protection for clients, practitioners and the practice
  • Can be used for data and research
  • Helps you with correct medical coding
  • Allow faculty to train and provide quality assessment and review of staff practices
  • Help with optimal care of the client

Now that it is clear how to draft daily session notes, the next step is to understand when the notes should be complete. The daily session notes should be completed in seven days from the date of service. The discharge summary should be completed within 30 days of discharge. It is important to know the state and federal policies for the service area.

With advanced technologies, there are new and advanced ways for healthcare providers to monitor and treat injured or ill people. They can rely on medical transcription services to ensure timely injury documentation. These services also have trained medical transcriptionists who are specialized in areas like pathology transcription, orthopedic transcription, cardiology transcription and other medical specialty transcription.

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