What Is The Best Dictation Workflow For Your Needs?

25-October-2021 MTS TEAM Medical Transcription

Dictation Workflow

Electronic health records (EHRs) contain a wide spectrum of patient information – from patient medical history, diagnoses, medications, treatment plans to immunization dates, allergies, radiology reports, and much more. Physicians are not data entry experts and they prefer to dictate medical information. Medical transcription services ensure timely and accurate physician dictated reports. However, there are other ways physician dictation is documented in the EHR, including using specialized software. It is up to physicians to select the best dictation workflow for their needs. Let’s take a look at different options available for EHR documentation.

Digital voice dictation and medical transcription service: In this simple system, the physician speaks and the dictation is captured by a digital recorder. The audio file containing the physician’s dictation is transferred to an in-house medical transcriptionist or sent to a medical transcription company using an easy and secure upload and downloading system. Leading companies have experienced teams of transcriptionists, editors and quality assurance experts to ensure error-free, timely transcripts. Once the files are transcribed, the company will deliver them using the FTP or 256 bit AES encryption over the internet using the client’s browser. Medical transcriptionists may also enter the dictated words directly into the electronic medical record (EMR). The physician will review the transcribed notes for accuracy.

This type of workflow is suitable for practices that prefer human transcriptionists who convert the physician’s dictation into text in the required format. Physicians don’t need to train themselves to use new software. Outsourcing medical transcription is more cost-effective than in-house transcription which would require hiring and training certified transcriptionists and investing in the latest equipment.

Speech-to-text or automatic speech recognition (SR) with editing support: Automatic speech recognition (ASR) has revolutionized the way physicians do dictation. Speech-to-text recognition software convert the human voice into written text in real-time. Physicians can dictate patient details including vitals, observations, treatments and medications prescribed, etc., and all of the audio is transformed into a detailed narrative by the program. Advanced software can accurately transcribes medical terminologies such as medicine names, procedures, and conditions or diseases. This option is user-friendly quick, convenient, and cost-effective, and saves physicians’ time.

This workflow option may be more economical than digital voice dictation and manual transcription, but the cost of the software needs to be factored in. It is also reported that error rates are high with speech recognition software and the transcripts would need to be reviewed and edited. Physicians can outsource this task to a medical transcription company. According to a study funded by the Agency for Healthcare Research and Quality, the error rate in SR generated documents fell 0.3% following editing by a transcriptionist and the dictating physicians’ final review. This option is ideal for physicians who lack time for reviewing their transcripts.

EMR-integrated speech-to-text solutions: Advanced medical dictation software is designed to input physician dictated notes directly into the EMR/EHR. The software leverages SR, AI, machine learning, and natural learning processing (NLP) technologies to effectively transform speech into text, as well as archive recorded dictations. Voice assistant tools help physicians overcome challenges associated with conventional EHR interfaces and navigate the EHR more efficiently. Physicians can use their smartphone to dictate and send their files, and the software will feed the text into the appropriate sections of the EHR. The notes appear on the screen immediately and can be reviewed and edited by the physician.

EMR-integrated speech to text solutions are easy to implement and physicians do not need much training. The American Medical Association (AMA) references one expert as saying that Speech-recognition software allows physicians to “think out loud”, and this leads to richer content, less cutting and pasting of notes, and more complete problem lists.

However, errors are still a concern and physicians would have to spend time proofreading the notes. One study found that seven in 100 words in unedited speech recognition-generated documents had an error and one in 250 words contained a “clinically significant errors”.

Mobile speech-to-text dictation: This option is similar to the above-mentioned one, except that the dictation into an app on a desktop or directly into the EMR is done from a mobile device. According to Mobius MD, this option is suitable for physicians who are comfortable with technology and willing to explore new dictation workflows. Nuance, Philips, 3M and M*Modal, Dragon Anywhere are popular speech recognition software that allow physicians to capture notes on their smartphones. Physicians can dictate documents of any length, and easily edit, format and share from their smartphone or tablet. Mobile options allow physicians to dictate clinical notes from wherever they are – their home, car, or any other setting.

Physicians need to evaluate each of these medical dictation options carefully and choose the most suitable one. Even if they decide to implement innovative dictation technologies, they still need to review and edit their documentation. Experts highlight the main issues with voice recognition and AI-backed programs as lack of contextual comprehension and the tendency to misinterpret and mistranscribe words. That’s why outsourced medical transcription service providers continue to be relevant.

Human medical transcriptionist are well-versed in medical terminologies and stay up to date on medications, maladies, treatments, and testing and this knowledge makes the documents they create more accurate and comprehensible (www.healthitoutcomes.com). In fact, physicians who implement automated dictation workflow and EHR documentation solutions need to ensure proper review precautions to avoid exposing themselves to law suits and costly medical litigation.

Medical Transcription Market To Witness Significant Growth By 2025

21-October-2021 Julie Clements Medical Transcription

Medical Transcription Market

Medical transcription plays a key role in accurate medical documentation. With support from reliable EHR integrated medical transcription services, physicians can save valuable time to focus on providing better patient care. According to a report from Technavio, the medical transcription market has the potential to grow by USD 23.03 billion during 2021-2025, and the market’s growth momentum will slow down at a CAGR of 6.40%. The estimated year-over-year growth rate of 2021 is 8.97%. The industry is also expected to be impacted by the spread of COVID-19 pandemic and predicted to take more than two quarters (six months) to reach a normal state of economic activity. In the short term, the market is expected to show growth due to the increase in infections and reduced economic activity.

Key factors driving the medical transcription market growth are –

Increase in need for automated transcripts, and
Emergence of voice recognition technologies

However, increase in medical data privacy concerns is an important factor that may impede market growth.

The report divides the market by end-user and geography. End users of this market are – hospitals and physician groups and clinics. Region-wise, the market is divided into North America, APAC (Asia-Pacific), Europe, South America, and MEA. 35% of the market’s growth will originate from APAC during the forecast period. Japan is the key market for medical transcription in APAC. APAC has been recording a significant growth rate and is expected to offer several growth opportunities to market vendors during the forecast period, owing to factors such as increasing chronic diseases and aging population.

The report also provides information on several market vendors, including 3M Co., Acusis LLC, CareCloud Inc., Excel Transcriptions Inc., Global Medical Transcription LLC, iMedX Inc., Lingual Consultancy Services Pvt. Ltd., Nuance Communications Inc., and World Wide Dictation Service of New York Inc. among others. The market is fragmented and the vendors are deploying various organic and inorganic growth strategies to compete in the market. To make the most of the opportunities and recover from post COVID-19 impact, these vendors are advised to focus more on the growth prospects in the fast-growing segments, while maintaining their positions in the slow-growing segments.

Hospitals and other providers can consider outsourcing medical transcription tasks to reduce costs and improve the quality of medical documentation. Many practices now rely on transcription software to get automated transcripts within short turnaround time. Though such software has easy voice capture and speech recognition capabilities, the accuracy of the transcripts may be compromised. To ensure better accuracy, practices can consider hiring the services provided by editors in professional medical transcription companies.

At MOS Medical Transcription Services, we provide transcription to healthcare clients across the United States and worldwide. Our team has several years of extensive experience in multi-specialty transcription. All transcripts are checked by our QA team to make sure that the quality of the work is always maintained.

Call us at 1-800 670 2809!

How A Medical Transcription Service Can Resolve EHR-Related Problems

18-October-2021 Rajeev Rajagopal EHR Transcription

EHR

Electronic Health Records (EHRs) were introduced with the objective of standardizing patient data and ensuring better access to it. The process of EHR documentation is simple and easy – just click, input data and save. However, in reality, users don’t find EHR documentation quick and easy. With EHR system, physicians are forced to spend their valuable time on the computer capturing patient’s medical information and tend to miss out opportunities to engage with patients during the office visit. Studies have shown that physicians spend one third their time in exam room looking at the computer screen. Medical transcription services are a practical solution to this problem. Healthcare units now address EHR-related data entry issues with EHR-integrated medical transcription solutions.

Issue with Adopting EHRs

The Electronic Medical Records (EMR) Mandate requires all healthcare providers to convert all medical charts to a digital format. But it took a long time for healthcare provider to implement EHR system. This was mainly due to cost involved in EHR adoption. In 2009, the Harvard School of Public Health published a study on why hospitals in the U.S. were slow to adopt EHR technology. The study concluded that less than 2% of surveyed hospitals had implemented a comprehensive EHR system. According to The Office of the National Coordinator for Health Information Technology, in 2017, around 95 percent of hospitals used a certified EHR system. Almost all large and medium-sized hospitals had implemented an EHR, with small, rural hospitals at 93 percent.

After the implementation of EHR system, physicians were forced to spend more time on documenting medical records and this led to physician burnout. Stanford Medicine published a study in 2018 which reported that 74% of surveyed physicians said that using the EHR system had increased daily hours worked. Around 69% said that using an EHR platform takes valuable time away from seeing patients.

Another concern in the implementation of EHR is data input. Patient are concerned about how and when their medical records are shared. The issue of how and who enters data into an EHR is an overriding issue. Inputting data into EHR is a tedious task for healthcare providers. Both physicians and patients say that when doctors spend more time during an exam entering data into a computer or portable device, neither are satisfied with the outcome. This has led to many physicians hiring virtual scribes to input patient data into their EHR system. The adoption of speech recognition technology allowed recorded conversations to be automatically documented and inputted into the EHR. But due to the complex terminologies used in healthcare, this often led to errors.

The current solution is the balanced approach which involves EHR-integrated medical transcription services. Practitioners record conversations of their patient interaction and have the audio files converted to written format by a medical transcription company. Skilled documentation specialists are trained workers who can capture accurate information without any errors or duplication. With accurate medical records, patient safety, reimbursements and risk management goals are all met which improves the efficiency of the organization. So, from a practical point of view, medical transcription plays a vital role in EHR documentation.

Not all medical transcription providers are the same, so it is important to choose a reliable service. The medical transcription service company must be HIPAA compliant and can ensure error-free and timely clinical documentation.

How To Implement Remote Patient Monitoring Effectively

14-October-2021 MTS TEAM Medical Transcription

Remote Patient Monitoring

Remote patient monitoring (RPM) is the use of digital health devices to monitor and capture health data from patients and transmit this information to healthcare providers for assessment and care recommendations. Connected health devices include everything from wearable heart monitors, blood glucose meters, spirometers and pulse oximeters to ECG machines Fitsbits, and Bluetooth-enabled scales. By tracking patients’ blood pressure, glucose levels, temperature, weight, pulse, oxygen levels, and other vital health data via RPM, physicians can keep an eye on them between office visits. With the COVID-19 pandemic, RPM and telehealth adoption saw a surge, helping connected patients receive continuous care at home. Medical transcription companies provide accurate and timely documentation of these virtual encounters in the electronic health record (EHR).

However, according to a recent Medical Economics article, most RPM solutions have not lived up to expectations because they are not developed specifically with the senior population (75 and older) in mind. Many older adults have serious chronic conditions such as high blood pressure, diabetes, and congestive heart failure which require consistent monitoring and easy access to care. The report lists several reasons why RPM does not work effectively for seniors:

They do not have unrestricted and high-speed internet connectivity.

They are technology challenged – they may not always have the help they need to use digital technology.

The technology they are provided with is not sufficient for their needs because “designed for another primary use and retrofitted for RPM”.

Given these issues, let’s take a look at the key considerations for effective implementation of RPM:

Proper planning and coordination between teams involved: According to a HealthTech Magazine report, proper RPM planning requires both the participation of the clinical group as well as the IT team. The clinical group should identify the patient population that will be monitored, the problem it’s trying to solve with RPM, and how monitoring will be done. The IT team should handle the technicalities as clinicians usually don’t have experience in this area.

Communicate the objectives of RPM clearly: To ensure participation, both clinicians and patients should clearly understand the goals and processes of RPM. Patients should know how they can convey their measurements electronically. Clinicians must be able to identify patients who are having problems. There should be processes in place to handle emergencies.

Implement simple, customized at-home RPM solutions: To connect with patients, facilities should use simple, easy to operate RPM options like structured discharge phone calls or an automated phone system. Tablets or iPads modified as RPM consoles or equipment retrofitted from use in hospitals would be too complex for seniors to handle. Even the highest sound level on a tablet would not be audible to seniors with hearing problems. There are simple RPM approaches for a range of diseases, from congestive heart failure (CHF) to diabetes and monitoring these conditions remotely using simple approaches allow for quick interventions such as changing medication prescriptions or increasing the dosage.

Choose the most suitable device: The digital literacy of seniors is a very real concern when it comes to embracing healthcare technology. In a recent survey, 61% of physicians reported that lack of digital literacy among patients is a major hurdle to telehealth. Ease of use, especially by seniors, is critical to boost adoption. Here are some recommendations with regards to this:
- The RPM device must be “plug and play” without a complicated setup.
- Vital sign monitors must be pre-set and work without a hitch when patient use them.
- Voice communications should be automated and foster patient engagement.’
- It should be possible to activate two-way communications at the push of a button.
  - Using RPM cellular devices is a good option as they are faster, and reliable internet access is not required.
Leverage AI and automation: The continuous monitoring of multiple parameters would result in the rapid increase in unprocessed and unorganized data available for clinical decision-making. AI can help healthcare providers extract actionable information from this data. AI powered data analytics is crucial to take advantage of innovative trends in patient monitoring technology such as smart prosthetics and smart implants for patient management post-surgery or rehabilitation, solutions for wound management and cardiac monitoring, and brain-computer interfaces to monitor and evaluate patients’ psychological, emotional and cognitive state. Advances in AI and automation also allow patients to easily connect directly with a healthcare provider and for the clinicians to respond.

Round-the-clock monitoring: To ensure that patients have access to 24/7 care, RPM providers must partner with a care management company that monitor patients and deliver the physicians’ protocols (www.medicaleconomics.com). Both stakeholders work to implement and incorporate RPM into current physician workflows for enrollment and care delivery services.

Offer comprehensive solutions: Utilizing multiple tools to track their health can be difficult and confusing for seniors. They should be provided with complete solutions such as blood pressure monitors and oxygen sensors that integrate easily with the system and each other.

The pandemic exposed the need for the rapid adoption of increasingly innovative digital health technologies. According to a recent mhealthintelligence news report, with the surge in the popularity of RPM, telehealth advocates are lobbying the Centers for Medicare & Medicaid Services (CMS) to improve proposed coverage plans in the 2022 Physician Fee Schedule. As healthcare facilities work to implement innovative strategies to connect with and care for patients at home, they can rely on an experienced US based medical transcription company to document virtual consults in the EHR.

What Should Be Included In Nursing Documentation?

11-October-2021 Julie Clements Nursing Transcription

Nursing Documentation

Nurses work demanding shifts and managing documentation can be a phenomenal task. Keeping accurate and timely nursing records is essential for communication among all members of the patient’s healthcare team and to support the delivery of safe, appropriate and continuous care. Good records allow healthcare providers to identify problems and the action taken to correct them. Nursing transcription is a viable strategy to ensure accurate and timely electronic health record (EHR) documentation. For clear, concise and comprehensive patient charts, nursing documentation should include all the essential components with regards to professional nursing standards.

Guidelines for Nursing Documentation

The American Nursing Association (ANA) has set down primary guidelines that serve as the gold standard for the basis of nursing documentation. The ANA defines high-quality nursing documentation as inclusive of the following characteristics: “Accessible, accurate, relevant, consistent, auditable, clear, concise, complete, legible/readable, thoughtful, timely, contemporaneous, sequential, reflective of the nursing process, and retrievable on a permanent basis in a nursing-specific manner.” The ANA further states that all entries in the medical record must be legible/readable and that standardized terminology should be used to describe the planning, delivery, and evaluation of nursing care.

Essential Elements of Nursing Documentation

Nurses are usually responsible for creating the patient chart and updating all information from vital signs to the patient’s pain level and other parameters, and any progression of symptoms or emergencies the patient experienced during the hospital stay.

The patient’s EHR should have the information necessary to support informed decision making and high quality care by the care team. Timely documentation of the following aspects regarding the patient should be maintained in the medical record:

Evaluations

Clinical problems

Communication with other healthcare providers

Communication with and education of the patient, family, the individual designated as the patient’s caregiver and other third parties

Medication records

Order acknowledgement, implementation, and management

Clinical parameters

Responses and outcomes, including changes in health status

Plans of care that take the patient’s social and cultural needs into account

Writing The Nursing Note

Nurses generally follow the S.O.A.P. (Subjective, Objective, Assessment, and Plan) format when writing progress reports.

Subjective: The date and time, the patient’s name, the names of the doctor and nurse, general description of the patient and reason for the visit is documented. The subjective section includes information gathered from the patient or family members/caregiver about the reason for the visit, the patient’s health, and symptoms the patient is experiencing such as pain.

Objective: Objective information to include in the note includes vital signs – body temperature, pulse rate, respiration rate, and blood pressure, evident symptoms and results of laboratory tests ordered by the physician. By supporting the subjective data, objective information helps the physician with diagnosis.

Assessment: This section of the nursing note includes information about the patient’s condition based on the assessments done. It should list medications prescribed, the response to them, and any changes are noticed in the patient’s condition after admission.

Interventions and Care Plan: This section records details about the care the patient received during the nurse’s shift. Information can be provided about the times medication were administered, requests made by the patient, and additional observations made about the patient’s condition. The care plan section of the nursing progress note should include any intervention planned for the benefit of the patient.

A paper published in Community Eye Health advises nurses that if they have any doubt about what to include in the note, they should ask themselves the following: “If I was unable to give a verbal handover to the next nursing team, or the next shift, what would they need to know in order to continue to care for my patients?” The goal should be to ensure that patient’s care is not affected by the change of nursing shift.

Tips for Keeping Good Nursing Records

Ensure clear, legible records

Record all relevant observations in the patient’s nursing record, as well as on any charts throughout the day so that important details on the patient’s status are not left out.

Sign each entry, giving your full name and aim to record the exact time of the patient visit,

Include medications given, dosage, the time they were administered, and reactions of the patient to the medications

Clearly state the diagnosis as well as any problems the patient is experiencing (like pain), and treatment administered

Make notes of all allergies, including allergies to medications

Document physician consultations, including time, remarks, patients response and actions prescribed

Note all pertinent observations in the patient’s nursing record, as well as on any chart

For hand-written notes, consider using only blue or black ink. If you make a mistake, cross it out using a single line and sign it.

For a patient scheduled for surgery, make sure to include the consent form for the operations signed clearly by the patient in the record. Also create a nursing checklist to ensure that the patient is prepared for the scheduled surgery.

Record all discharge plans

Maintain HIPAA compliance and protect the patient’s confidential information.

Document the patient’s wishes

Avoid jargon, meaningless phrases, or personal opinions

Use only familiar and commonly understood abbreviations (for example, BP for blood pressure, DM for diabetes mellitus, VA for visual acuity)

All statements should be factual and recorded in the order they happen. Don’t not speculate, make offensive statements, or joke about the patient

Accuracy in nursing documentation is crucial since physicians, nurses and other healthcare providers depend on the patient’s chart to provide care. Outsourcing nursing transcription to an experienced medical transcription company is a practical way to ensure accurate, timely, and detailed documentation that provides evidence of the level and quality of the nursing care provided.

View our infographic on Key Elements In Nursing Documentation [INFOGRAPHIC]

How To Prevent Laboratory Notes Transcription Errors [INFOGRAPHIC]

07-October-2021 Rajeev Rajagopal Infographics

To ensure accurate and complete clinical documentation, many healthcare facilities rely on experienced medical transcription companies that provide EHR/EMR integrated transcription services. Laboratory notes are an important component of medical records. They include crucial details such as the experimental plans, observations, discussion of results and more. When entering words and sentences in a laboratory note, transcription errors such as incorrect test entry, incorrect spellings, repeat typing, wrong time or dates specified etc. can occur.

The International Journal of Health Care Quality Assurance has discussed Six Sigma tools to help identify and solve laboratory data entry quality problems. These QI tools include steps such as – Define, Measure, Analyze, Improve and Control (DMAIC). This Six Sigma DMAIC method is reported to reduce data entry errors considerably.

Check out the infographic below

Laboratory Notes

How To Use Medical Dictation Software Effectively

04-October-2021 MTS TEAM Medical Transcription

Medical Dictation Software

In the world of healthcare, speed, efficiency and accuracy are paramount. But a recent study by the American Medical Association found that physicians spend nearly half of their workday on EHR documentation. This can significantly affect the time spent on patient care.

Medical dictation software is a valuable tool for time-strapped physicians. With extremely packed schedules, long work hours, and numerous patient appointments and administrative tasks to juggle, physicians have limited time available during the workday. Medical dictation software is a useful tool in this situation that listens to their patient consultations, and automatically takes notes on the user’s mobile, laptop or workstation. There is a wide range of medical dictation software tools that work on all EHR platforms. Nevertheless, medical transcription services continue to be relevant to review and improve the accuracy of speech recognition generated documents.

Take your documentation to the next level with our professional medical transcription services!

Call (800) 670-2809 today!

Medical dictation software uses a microphone to record voice and instantly translates what it hears. It eliminates typing, saves time on clinical notes, improves productivity, and can be accessed from anywhere and reused. AI-powered medical scribes recognize spoken words, phrases and keywords and convert them into legible text in real time. It takes the stress out of documentation and frees up the physician to focus on the patient. These tools generate clinical documentation that can be integrated into the electronic health record (EHR). However, to experience the full benefits of the technology, it’s important to use it effectively.

Tips to Maximize the Potential of Medical Dictation Software

Choose the Right Software

Different medical practices have different requirements, which can range from compatibility with specific EHR systems and support for multiple languages, to advanced editing capabilities. Start by assessing your needs and determine what features are most important for your practice. Modern speech to text software comes with a wide range of functionalities. A popular option, Dragon Medical One offers highly accurate real-time medical speech recognition, customizable vocabularies and templates, and cloud-based for accessibility across devices. Otter.ai, another advanced medical dictation tool, comes with a user-friendly interface, supports collaboration with sharing and editing features, and integrates with Zoom and other conferencing tools. Google Docs Voice Typing supports multiple languages. Nuance Dragon Professional Individual, Mobius Scribe, Microsoft Dictate, and Speechmatics are other top medical dictation options.

Research and compare these options. User reviews, demos, and consultation with colleagues can help you find the best product for your needs.

Invest in Quality Hardware

Dictation software can ensure accurate note-taking only if the audio input is good. Invest in a high-quality microphone that minimizes background noise and captures your voice clearly. Additionally, make sure that your computer and mobile device is compatible with the dictation software. Check for system requirements and compatibility with your existing EHR systems.

Choose a Quiet Environment

Minimize background noise before you begin dictation. Background noise can interfere with the software’s ability to accurately transcribe your speech. Dictating in a quiet environment can help the software adapt better to your voice and background noise levels, improving accuracy over time.

Understand How the Tool Works

Advanced apps make your mobile device a microphone that can dictate directly into any software on any computer and uses deep learning and neural net technology to adapt to your voice patterns. As your license learns your voice pattern and nuances, it is completely customized to you.

Starting dictation and transcription is easy. Open the software and turn on the microphone. Then place the cursor in the place you want text to be inserted and begin speaking in your normal speaking style and speed. On Dragon Medical One, you can speak through the headset attached to the clinical workstation, or use your smartphone by installing the PowerMic Mobile app on your mobile device. Dragon listens to you speak and uses AI to transcribe the words on your behalf. Once you’ve finished your dictation, log out of the app.

Position the Microphone Correctly

In sound-sensitive apps, even minor changes in mic position can make a big difference in volume and amount of sounds that get transmitted. When using a headset, the microphone element should be positioned between 3/4 inch to 1 inch away from your mouth. For a hand-held microphone, the proper distance is typically 2-3 inches from your mouth. The appropriate range for a desktop microphone depends on the specific design, but most require a distance of 3-5 inches between your mouth and the microphone element. With Dragon Medical One, it is recommended that the microphone on your phone is about 1 to 3 inches from your mouth and off to the side (hopkinsmedicine.org). Press and hold the microphone button for a half-second before talking. Speak directly into the microphone, not across it. For SpeechWare “TableMike” models, the recommended mouth-to-mic distance can range from about 10 to 24 inches.

Optimize Accuracy

Optimizing accuracy with speech recognition is in your hands. Here are the things you can do to ensure accurate note-taking:

Speak clearly and at a moderate pace. Avoid mumbling or speaking too quickly, as this can lead to transcription errors.
Speak with a normal or conversational volume, that is, don’t speak too loudly or softly.
Think before you dictate and use phrases or complete sentences.
Avoid mumbling. Speak slowly and distinctly – this is the most important thing when it comes to accuracy.

Use Voice Commands Correctly

Apps allow you to dictate commands and punctuation to tell your PC what to do and save time In some apps like Mobius Scribe, numbers are given as words (not digits), unless dictated together with dates, date ranges, times, measurements, dosages, and symbols. Learn to use dictation commands:

Ask for a list of commands
Pause briefly after a command to ensure that it is interpreted as a command and not processed as text
Say the words “colon,” “new paragraph” or “end sentence”, delete that, “select all”, etc.
Say “cap” to capitalize a word, or “all caps” to capitalize all letters in the following word
To provide a number in digits, say “numeral” followed by the number
Dictate symbols – say “plus sign” for +, “percent” for %, etc.
Use commands to type, hold, and hit keys on your keyboard.

Ensure Consistent Use of Terms

Use consistent medical terminology and phrases. This helps the software learn and adapt to your specific language patterns, increasing accuracy. Many dictation software solutions allow you to add custom vocabulary, including medical jargon, patient names, and frequently used phrases. Regularly update and refine your custom vocabulary for better accuracy. Leverage templates and macros to quickly insert common phrases or structures into your documentation. This can save time and minimize repetitive dictation.

Proofread and Edit

While medical dictation software is highly accurate, it’s not infallible. Best practice is to review the transcriptions for errors. In fact, many healthcare providers outsource this task to a medical transcription company in the US, Having your AI-generated transcripts proofread by experienced human medical transcriptionists will ensure that your documentation is precise and free from mistakes. Many software applications can be trained to correct mistakes. This ongoing learning process allows the software to continuously improve its accuracy over time.

Create Auto Text

The auto text feature allows you to automatically create specific text for frequently used language, which can reduce mistakes and save time. Auto texts are used for normal patient status notes, signatures, and frequently typed addresses. On Dragon Medical, open the Auto-text window through the context menu or the “manage auto-texts” command. Then click+ and add a new entry and fill in the material that you want to appear when you say a specific word. Hit apply all and close.

Add Medical Vocabulary, Words and Phrases

All leading medical dictation systems understand medical vocabulary. However, you may come across words that the software doesn’t spell correctly the first time. In such situations, you can teach your app new medical vocabulary, words and phrases. For instance, to update your dictation vocabulary in the Mobius Conveyor medical dictation solution, follow these steps: Go to Vocabulary by swiping left from the live screen, tap the “Add vocab” button, and type the new term you want to add under “Written Form”. You can check if the app will get it right by tapping the “try it out box” below and speaking a sentence with the new word.

Stay Updated

To benefit from the latest features and improvements, regularly update your dictation software. Updates typically include enhancements to accuracy, security, and compatibility. Many providers offer resources, tutorials, and support to help you make the most of their product. Stay informed about these new tips and best practices for using your specific dictation software.

Medical Dictation Software

Outsource the Proofreading Process

Medical dictation software can be a powerful tool for healthcare professionals, streamlining the documentation process and improving accuracy. It may take some time to learn and get used to all the features of medical dictation software, but once that’s done, you will be rewarded with real-time, quality transcription without having to do any typing. Today, busy physicians who use speech recognition software can boost documentation accuracy by relying on a HIPAA compliant medical transcription company for proofreading and quality assurance checks.

Partner with our medical transcription company to boost efficiency and accuracy!

How To Prevent Common Types Of Transcription Errors In Laboratory Notes?

30-September-2021 Julie Clements Medical Transcription Company

Transcription Errors

Laboratory notes include crucial details that are used to write laboratory reports. These notes include observations of experiments and collected data points and the reports must be error free to help physicians reach the right diagnosis and treatment decisions. An experienced medical transcription company can provide EHR/EMR integrated transcription services to ensure accuracy and completeness in clinical documentation.

The common transcription errors encountered when entering words and sentences in a laboratory note include

hitting the wrong key
incorrect test entry
typing incorrect spellings
priority entered incorrectly
leaving out important details
wrong time or dates specified
missing venipuncture charges or
repeat typing

Manual data entry process can produce many errors, which can have a significant effect on other laboratory sections, clinical care, and ultimately, patients.

Six Sigma QI Tools to Improve Laboratory Data Entry Quality

A July 2013 article in the International Journal of Health Care Quality Assurance discusses Six Sigma tools that helped the Six Sigma Quality Improvement (QI) project team define project goals, measure data entry errors to assess current performance, analyze data and determine data-entry error root causes. These tools assisted the team in implementing changes and control measures to address the root causes and to maintain improvements. Six Sigma is a systematic five-step process to help identify and solve problems: Define, Measure, Analyze, Improve and Control (DMAIC).

1. Define the Problem

To properly define the problem, three effective tools can be used –

1. Answering the quality-related critical questions
2. Customer Voice (VoC) to better understand the laboratory customers’ views and needs to focus on meeting their expectations
3. Data Entry Process Mapping, which is a workflow diagram that helps to clearly understand the process.

Mapping is a helpful tool prior for any process improvement and to achieve efficiency. Analyzing the data entry steps helps understand the process and develop improvements by eliminating unnecessary tasks, clarifying roles, reducing unnecessary delays and eliminating duplication.

2. Measure the Process

In this stage, the performance of the data entry process is assessed. The data is reviewed data and additional indicators to measure are identified. Here, the team can measure concerns such as – what problems need addressing, when the problem occurs, who needs to be involved, what is the business significance of solving the problem and What is the desired Process Improvement (PI) outcome. Unclear forms pose a major problem, as extra time would be required to clarify information. Error frequency can also vary depending on the individual’s data entry skills.

3. Analyze Data

The main purpose in this stage is to analyze the root causes of problems identified in the measurement stage. Here, the team can work to identify variations, gaps between current performance and customer expectations and then decide significant root causes they need to focus for improvements.

4. Improve the Process

In the Improve stage, the team can aim at designing creative solutions to fix the root causes that were identified after measuring and analyzing the data. They can work to minimize or eliminate data entry errors by creating innovative solutions using existing technology and simple process redesign. An implementation plan can be put in to effect to implement changes and monitor data entry errors.

5. Control the Changed Process

In the final stage, the team can create quality management tools to help manage the improvements, keep the process going, and prevent errors. They can develop and implement a monitoring plan to track all data entry errors, inform staff of monthly quality-indicator progress reports, create and share tips and best practices among staff, encourage laboratory staff to learn data entry, and complete competency evaluation.

The team has reported that after applying the Six Sigma DMAIC method, significant improvements in staff morale, operational and financial outcomes were realized and data entry errors were reduced considerably. In clinical laboratories, the opportunity for successfully implementing Six Sigma is greater than in many healthcare areas. These tools were used to target root causes in the laboratory process.

Other suggestions to avoid data entry errors –

Focus on accuracy as well as speed
Take regular breaks, as data entry over extended periods can get monotonous
Choose in a comfortable place to work in that is free from distractions
Make sure to have an ergonomically designed chair and work table
Adopt user-friendly software to save valuable time and reduce errors
Assign a quality assurance team to double check the data entries

Ensuring accurate data entry is a critical task for any laboratory. Practices can rely on pathology transcription services to get quality transcripts of diagnostics reports, specimen diagnosis, doctor’s notes, forensic pathology reports, and more.

How Can Physicians Save Time On EHR Documentation

27-September-2021 Rajeev Rajagopal EHR Transcription

EHR Documentation

Many physicians find electronic health record (EHR) documentation tedious as it involves too much time doing data entry which takes away from direct eye contact with patients. Physicians need to document each patient interaction correctly and as soon as possible to maintain the integrity of the record. Medical transcription outsourcing is a feasible strategy to create accurate, integrated and complete digital patient medical records from your notes. Here are some useful strategies you can consider reduce your work load and save time on EHR documentation, including strategies recommended by the American Academy of Family Physicians (AAFP).

Rearrange your Exam Room: The computer should be positioned in a way that allows you to see both the patient and the screen with just a minimal shift in gaze. The aim should be to avoid any position where you have your back to the patient, as if you do, you could miss crucial nonverbal clues, besides straining your neck! A computer or monitor that swivels or a wireless medical computer workstation on wheels are popular options user-friendly, ergonomic options.

Use Two Screens for Televisits: For a telemedicine setup, the AAFP recommends two screens – one that shows the patient and another for EHR documentation. You should be able to see the patient and the digital medical record with just a slight shift of your gaze. Consider a tablet to communicate with the patient and a desktop or laptop for EHR display.
Leverage EHR Capabilities and Hacks: EHR templates are designed to promote structured and efficient documentation of care and eliminate the need to type out words or phrases.
- Use templates for physicals, routine office visits, televisits, procedures, patient instructions, specific exams and health parameters. Insert the automatic list of the patient’s diagnoses and related orders in the template into the assessment/plan and type in only the remaining few details.
- Automatically extract problems and diagnoses from assessments and plans, instead of repeatedly documenting each problem.
- For questions that have options that are short responses that do not need lengthy answers or elaboration, use the form fields or checkboxes. This can help minimize errors, improve understandability, and save time on documentation.
- EHRs also feature shortcuts called smart phrases or dot phrases that save physician time. Learning how to use EHR templates and smart phrases can help you capture the key elements of the visit with minimal effort. Dot phrases can help with proper documentation of common procedures and office visits, manage your inbox, and much more. However, while using these well-rounded phrases, make sure that the action noted in the smart phrase is actually performed.
Stick to Short Notes: In order to meet billing requirements, physicians tend to write excessively long notes in the EHR, which is not only time consuming, but also leads to “note bloat”. Avoid long notes when documenting the history of present illness (HPI). Document the medical visit clearly using short phrases to identify each complaint. Ensure that you use semi-colons to separate each phrase. Use two spaces and another line to document a separate complaint.

Use Online Patient Questionnaires to Collect Data: Use questionnaires to collect information from patients for common situations, medical history, current medications, and review of systems. This can save time that would go into asking patients questions during the consult.

Train your Dictation Software to Increase Accuracy: Dictation systems may misrecognize certain words or commands during your dictation. Make your dictation software more accurate and precise by training it on the correct pronunciation of specific words and commands. You can even train the software to recognize voice commands to add templates.

Use Copy-paste to Streamline Patient Education: A lot has been said about the time-saving copy-paste function in the EHR and how it can lead to errors that have legal consequences. However, copy and paste feature can be used safely to streamline patient education. Copy paste relevant information from the treatment plan into the patient instructions and save time on typing out the details. Leveraging audio or video patient education materials during the visit can also save time.

Other strategies experts (link.springer.com) suggest to improve the efficiency of EHR documentation include:

Develop novel ways to update standing lists, so that useless information is removed automatically.
Include anticipatory guidance in automated recommendations so that the system gets things done before the user does it.
Try to group related information together.
Make it easy to find information with a record
Use techniques that can reduce the number of clicks, including keyboard shortcuts, and make touchscreens available for selected functions.

The AAFP recommends using scribe or team documentation to save time on EHR tasks. Today many primary care practices rely on family practice medical transcription companies for EHR documentation support and also to review prior notes and ensure they are accurate, complete, and free of grammatical errors and typos.

Common Medical Record Documentation Errors To Watch Out For [INFOGRAPHIC]

23-September-2021 MTS TEAM Infographics

Incomplete and inaccurate patient records can compromise care. Documentation errors can result in wrong medical advice being provided, increased billing mistakes and loss of reimbursement. Medical transcription services play an important role in ensuring accurate and timely healthcare documentation. The key to ensuring accurate and complete clinical documentation is to recognize the common errors that can occur and take steps to prevent them.