HIPAA Confidentiality Regulations That Apply To Medical Transcription

20-September-2021 Julie Clements HIPAA Compliance

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) establishes the standard for protecting sensitive patient data or the confidential use of protected health information (PHI). “Covered entities” or “business associates” that handle PHI are required to be HIPAA-compliant. Covered entities refer to health plans, health care clearinghouses, and health care providers. Business associates mean all organizations or individuals who act as a vendor or subcontractor with access to PHI. A US based Medical transcription company comes under the business associate category and can be held liable for PHI exposure. That’s why you need to strictly enforce HIPAA transcription confidentiality regulations.

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What HIPAA Compliance Means for a Medical Transcription Company

HSS.gov defines a “business associate” as a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. As a business associate, a medical transcription company has to provide a written assurance or sign a contract with the covered entity or healthcare provider that it will appropriately safeguard patient identifying information. This means that the company must have the necessary infrastructure and regulations in place for securing and maintaining the confidentiality of PHI.

The HIPAA regulations that apply to a medical transcription company are as follows:

The company must ensure that the confidentiality, integrity, and availability of all PHI handled or transmitted is preserved.
It should not use or further disclose the information other than as permitted or required by the contract or as required by law.
It should implement appropriate safeguards to prevent reasonably anticipated but unauthorized use or disclosure of the information, including implementing requirements of the HIPAA Security Rule with regard to PHI.
The company must protect PHI it handles against reasonably anticipated threats to the security or integrity of the information.
It should ensure workplace compliance.

In 2022, an average of 1.94 healthcare data breaches of 500 or more records were reported each day (HIPAA Journal)

Measures for HIPAA Compliance

A HIPAA compliant medical transcription company will have proper measures in place to ensure security, health care compliance and privacy of PHI. Achieving HIPAA transcription compliance means your company has to maintain and implement effective written policies and procedures as well as implement administrative, physical and technical safeguards and controls to protect PHI:

Physical and Technical Safeguards

HIPAA compliant medical transcription means have the necessary physical and technical safeguards in place to protect PHI. This includes:

Measures to restrict physical access to computers and the facility or facilities in which they are housed, while ensuring properly authorized access is allowed.
Password protection for all computers and portable devices
Policies to secure PHI with specific controls such as strong passwords, email encryption, intrusion prevention software, locking down USB ports, etc.
Policies to protect the facility and equipment from unauthorized physical access, tampering, and theft.
Physical safeguards for all workstations that access PHI to restrict access to authorized users.
Procedures to create and maintain retrievable exact copies of EPHI.
Policies for guarding against and detecting malicious software.
Measures to report and address security incidents.
Policies and procedures for responding to an emergency or other occurrence, such as fire, vandalism, system failure, or natural disaster that harms systems that contain PHI.
Device and media controls for the receipt and removal of hardware and electronic media that contain PHI into and out of a facility, and the transfer of these items within the facility.
Technical security measures to guard against unauthorized access to PHI being transmitted over the internet.
Confidential patient information whenever appropriate.

Employee Training
Employees need to sign confidentiality agreements and be educated on the following:

Overall policies and practices to protect the security of electronic PHI in accordance with HIPAA rules
Responsibilities in protecting PHI, identifying HIPAA violations, handling sensitive data, password security, threat recognition, breach prevention strategies, and necessary documentation for mitigating breaches
Avoiding violations in social media use, public discussions of patient information, and accessing data on personal devices
Importance of regular annual training to keep up-to-date with the latest requirements

It is also essential to maintain documentation clearly listing the roles and responsibilities of all staff involved. HIPAA documentation provides evidence of the security measures taken to protect the confidentiality of patient information.
Audits
In addition to strictly implementing HIPAA confidentiality agreements, reliable medical transcription companies conduct annual audits to assess their administrative, technical, and physical measures. This helps identify potential vulnerabilities that can compromise the integrity and confidentiality of PHI. Measures can then be taken to minimize the risks.

HIPAA Compliant Medical Transcription: Safeguard Against Breaches

Earlier this year, a cyberattack on a U.S. medical transcription service resulted in the theft of highly sensitive personal and health information from nearly nine million patients, marking one of the most severe medical data breaches in recent history (TedCrunch).
What are the consequences of such breaches?
The stolen data poses a range of risks, including personal distress, identity theft, and reputational damage for affected individuals. Additionally, cybercriminals can exploit compromised accounts to breach enterprise networks, causing potential corporate harm.

For healthcare organizations, such breaches lead to severe consequences. Beyond reputation damage, they face substantial financial losses due to investigative expenses and potential legal repercussions.

Maintaining patient privacy and confidentiality is a matter of medical ethics, fostering trust between patients, healthcare providers, and transcription companies, all of which is fundamental for quality care.

Healthcare providers need to their research well and choose a US based medical transcription services that can provide accurate and timely EHR documentation, and also ensure the confidentiality of PHI with strict measures for HIPAA compliance.

HIPAA Compliance

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How To Write Good Mental Health Progress Notes

16-September-2021 Rajeev Rajagopal Psychiatry Transcription

Mental Health

Maintaining appropriate records of psychological services allows providers to monitor their work and promotes continuity of care. Good records protect both the patient and psychologist in the event of legal proceedings and are also essential for the psychologist to obtain appropriate reimbursement for services rendered. Psychiatry transcription service providers play a key role in helping mental health specialists ensure accurate and timely record keeping.

Mental health progress notes are the notes that psychologists, therapists, clinical counselors, psychiatrists, and other practitioners make at each session about the patient’s clinical status and may include important issues or concerns associated with the patient’s treatment over the course of care.

Functions of Mental Health Progress Notes

The functions of mental health progress notes include the following:

Provide Evidence that Competent Care was Provided: Progress notes allow a therapist to document their ongoing efforts to assess and manage the patient’s symptoms and also document their how they exercise judgment when dealing with complex and challenging treatment scenarios.
Demonstrate Medical Necessity: Insurers may require a provider to document the “medical necessity” for treatment in the patient’s record. Progress notes contain evidence of the patient’s need for treatment at a particular point in time.
Treatment Planning: It can happen that the patient is seeing the therapist again after an extended period of time. Progress notes serve to refresh the therapist’s memory. Different therapists treating the patient during a treatment episode refer to progress notes for specific clinical information pertaining to the patient.
Legal and Ethical Considerations: While there are no specific legal or ethical standards that govern the format or content of a progress note, as a general rule, therapists need to take practical steps to ensure accurate documentation that reflects the care provided.
Payer Requirements: Insurance companies or managed care organizations may have explicit practice guidelines and/or treatment standards with specific requirements for documentation of mental health services, including progress note entries.

Therapists use different formats and approaches to write progress notes, depending on the particular situation. For instance, while some clinicians keep detailed notes, others prefer to record only essential information. Many follow the S.O.A.P. format:

Subjective – The patient’s description of the problem/intervention
Objective – The therapist’s objective observations
Assessment – The therapist’s analysis of the various components in the subjective and objective sections of the note
Plan – A description of the treatment plan to the reach the goals or objectives (including additional tests to rule out or confirm a diagnosis, prescribed medication or surgical interventions, and follow-up)

However, some therapists may find the S.O.A.P. format cumbersome. The American Psychological Association (APA) states that up to the psychologist to balance various considerations and adopt the appropriate approach to keeping records.

Writing Therapy Progress Notes – Important Considerations

Here are 6 important steps to follow to maintain good mental therapy notes:

Meet the Necessary Requirements: Mental health progress notes need to meet their basic purpose and functions as defined above. The notes need to comply with state and federal laws and meet payer regulations. The documentation should provide evidence of quality care and decision-making for complex situations. The progress notes should provide communicate treatment plan information between providers, while meeting the specific requirements of the practice setting. Therapy progress notes may include: medical history, current condition, allergies, medications used and prescriptions, past treatment, diagnosis, symptoms, current treatment plan and modifications, interventions, progress or lack of progress, tests conducted and results, safety issues, treatment compliance/lack of compliance, collaboration with other providers, referrals made and reasons, and so on. To ensure the right level of detail, the APA recommends that psychologists balance client care with legal and ethical requirements and risks.
Be Clear, Legible and Specific: Mental health progress notes should be clear and legible and readable by other providers and authorized persons. Entries should be accurate and if possible made soon after services are provided. The documentation should be concise and specific, and cover all the information to justify medical necessity and the treatment approach.
Know HIPAA’s Distinction between Progress Notes and Psychotherapy Notes: Therapists who are HIPAA-covered entities should be knowledgeable about the concept of “Psychotherapy Notes” according to HIPAA. The HIPAA-created “Psychotherapy Notes” category is different from progress notes. According to HIPAA, Psychotherapy Notes exclude: “medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date”. This implies that HIPAA clearly excludes content that is ordinarily used to document the patient’s treatment, e.g., the content that is ordinarily noted in progress note (www.camft.org).
Be Knowledgeable about Terminology and have a Ready List of Frequently-provided Interventions: Progress note-taking involves documenting interventions and treatments. Knowing the terminology, appropriate language to use, and abbreviations is essential for better understanding and reliable reference. In fact, teams in a medical transcription company that provides psychiatry transcription services would be familiar with appropriate language and abbreviations used by therapists, and can ensure quick, error-free documentation of physician notes in the electronic health record (EHR). Mental healthcare software provider Quenza recommends that having a ready list of common interventions for quick reference would be very for practitioners involved in the patient’s care to understand the interventions implemented by others.
Avoid Shortcuts: Every time a progress note is created, it should include all the necessary information: the clinician’s full name, date, time, patient name, patient identifier and electronic signature. This is strongly recommended for legal and ethical reasons, especially in a multi-provider context.
Consider Patient Requests: Some patients ask their therapist to minimize documentation in the record in order to protect the information from certain parties or to avoid potential legal problems. In such situations, clinicians should maintain a balance between meeting documentation requirements and safeguarding the patient’s interests by separating discussions with patients from the rest of the medical record (www.therapynotes.com).

When maintaining mental health records, clinicians need to consider legal requirements, ethical standards, patient needs and other factors, as well as their particular professional context. Outsourcing medical transcription to an experienced psychiatry transcription service provider can help providers maintain accurate and timely progress notes as well as psychotherapy notes.

View our infographic on Tips To Write Good Mental Health Progress Notes [INFOGRAPHIC]

What Are The Documentation Requirements For ED Reports?

13-September-2021 MTS TEAM Emergency Room Transcription

ED Reports

Emergency Department (ED) documentation refers to the comprehensive records and notes created during a patient’s visit to the emergency room. These documents capture vital information about the patient’s medical history, symptoms, physical examination findings, diagnostic tests performed, treatments administered, medications prescribed, and any follow-up instructions given. ED documentation is unique because it is the only account of a patient’s ED visit and is completed under strict time constraints. As charting takes away from focus on patient care, physicians usually rely on emergency room transcription services to ensure accurate, detailed and timely capture of the patient encounter. Accurate documentation is crucial for continuity of care, ensuring accurate communication among healthcare providers, and to serve as a reference for future medical treatment or legal purposes.

If you didn’t document it, then you didn’t do it.

Importance of Accurate and Timely ED Charting

ED documentation provides a detailed account of the patient’s condition and the care provided during their emergency visit.

Accurate and timely ED charting is essential for proper communication. To provide the best patient care, healthcare providers who see the patient later need complete and accurate information about what was done in the ED. A report from www.saem.org notes: “Our chart is the main way we communicate with other health care clinicians (and even with patients) about what happened in the ED (e.g., diagnostics, treatments, our thought processes, discussions with patients and families about their concerns and desires, discussions with consultants about their recommendations and patient care plans)”.

Some other reasons why proper ED charting is crucial are:

Official record – The ED chart is the official record of the physician-patient encounter, H&P, and diagnostic and treatment plans.
Billing – The nature of the actions performed in the ER should be clearly documented to justify the level of billing reported.
Medicolegal defense – The chart should prove adherence to a high standard of care to serve as a defense in the event of a malpractice suit.

Good, clear ED charting is also critical for quality improvement reviews, research and utilization/risk management.

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ED Documentation Requirements

There are several reasons why ED charting is unique and distinct from other physician notes. The ED note is a stand-alone completed under tight time pressures. The physician needs to focus on being brief while conveying as much information as possible for present and future care. Though the medical decision-making process is based on limited information, the chart should show all differential diagnoses.

The ED note should include everything that is relevant to the patient’s complaint including the subjective, objective, assessment and plan (SOAP) portions. Here are the four key elements that the ED note should contain as listed by the Society for Academic Emergency Medicine (SAEM).

Subjective Portion
The subjective section should cover:
- The patient’s presenting/chief complaint or the reason why the patient is medical care as stated by the patient.
- The history of present illness (HPI) – the main aspects of a symptom of the chief compliant (like pain): onset, location, quality, severity, timing/frequency, alleviating factors, and aggravating factors (OPQRST).
To avoid note bloat, the American College of Emergency Physicians instructs that documenting or importing the patient’s entire past, family and social history from prior medical records is necessary only when they are clinically relevant to the current evaluation and management service.
- Over-the-counter and prescriptions medications, and any medication allergies.
For patients with more chronic problems – compliance with any medications or medication side effects, current symptoms or complications, end organ effects, and any health care needs related to the chronic illness.
Objective Section
The adage: “if you didn’t document it, then you didn’t do it” applies to this section.
- Include everything observed or measured during the interaction with the patient.
- Use standard medical language or commonly accepted abbreviations to report vital signs, general appearance, the relevant physical examination, and any laboratory or imaging results.
- Thorough physical examination documentation
- Results of any laboratory or radiologic studies ordered during the visit
Assessment Section
The medical decision-making process is recorded in this section. Documentation comprises the following:
- Summary Statement – concise summary of the chief complaint along with main elements of the subjective and objective sections
- Problem List – details of all problems
- Discussion of Differential Diagnosis – brief account of a probable differential diagnosis for each acute problem on the problem list
Plan Section
Each section of plan of action for the patient should be based in three things:
- Diagnostic recommendations – observation, laboratory tests, radiologic imaging, ECGs, or other diagnostic procedures
- Treatment options – medications and therapeutic procedures
- Follow-up plans – clear follow-up plan for future care

Role of Emergency Room Transcription Services

Emergency medicine practice involves multitasking to deal with complex clinical problems. Accurate, timely and detailed ED documentation is essential to show all differential diagnosis, high-risk conditions, and medical decision making. However, template-based software can often lead to inaccuracies and errors in the physician’s narrative. The solution is to add free text using dynamic templates, dictation, and medical transcription.

In 2017, the American Medical Association (AMA) reported on a study published in the Annals of Emergency Medicine that analyzed the effectiveness of electronic documentation in the ED. The lead author Joshua Feblowitz, MD noted: “The emergency department is a fluid and highly dynamic environment, with high volume, sick patients and frequent distractions and interruptions. The implementation of EHRs holds great promise in the emergency setting, but the environment is especially susceptible to changes that influence efficiency”.

The AMA report referenced Dr. Feblowitz, an emergency medicine resident at Brigham and Women’s Hospital and Massachusetts General Hospital as saying that adopting new workflow strategies and technologies can improve the efficiency of documentation in the emergency department. According to Dr. Feblowitz, the use of scribes and electronic dictation software are two specific interventions that have the potential to improve completeness and efficiency of documentation.

By capturing all aspects of differential diagnosis and medical decision making, an experienced emergency medical transcription service provider can help ED physicians ensure thorough and accurate ED documentation as they focus on providing the best patient care.

Importance of Proper Documentation in ED Reports

ED Reports

Essential Components of ED reports

Patient demographics
Chief complaint
History of present illness
Vital signs
Physical exam findings
Lab results and imaging studies
Diagnoses
Treatments provided
Discharge instructions

Benefits of Medical Transcription Services for ED Documentation

Accurate, timely and thorough documentation
Promotes high-quality patient care
Facilitates communication among healthcare professionals
Supports billing and reimbursement
Ensures legal compliance.

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What Is The Importance Of Keeping Proper Documentation Of Athletes’ Health Records?

09-September-2021 Julie Clements EHR Transcription

Athletes' Health Records

Athletic trainers (ATs) are highly educated and skilled professionals specializing in the management, prevention, and recovery of injured athletes. They work with coaches, physicians, and physical therapists. Documentation and computerized record-keeping are a crucial for ATs to maintain accurate, up-to-date, and complete information about patients at the point of care and ensure that patient records are readily available at any time. Accurate and timely documentation of injuries by ATs play a crucial role in reducing liability, tracking injury trends and making decisions about the best course of treatment. Partnering with a reliable provider of sports medicine transcription services is a practical approach to ensure efficient record-keeping.

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Importance of Documentation and Record-keeping in Sports Medicine

Accurate and up-to-date athletes’ medical records documentation:

Offers a complete, accurate and timely record of a patient’s complete medical history
Provides a record of the initial evaluation of a condition, treatments and interventions
Facilitates better patient management
Supports continuity of care
Serves as a valuable reference for treatment planning and evaluation
Reduces liability and provides protection in a legal case by giving evidence of what was or was not done in a given situation
Promotes compliance with medical industry standards and statutory regulations
Facilitates communication with multiple caregivers across various settings and ensures collaborative approach to care
Helps in claim submission for timely and appropriate reimbursement

Types of Records and Reports ATs Maintain

According to a report from Human Kinetics, ATs should document “any accident of which they are aware (even if it is not due to athletic participation), any treatment that an athlete receives, and the rehabilitation progress that an athlete makes”. They should document injury/illness prevention, education/wellness promotion, emergency care, examination and clinical diagnosis, therapeutic intervention and rehabilitation.

Different Types of Reports

ATs maintain different types of reports:

Accident and Injury Reports

athlete’s name and age
date of injury, date of the report
the athlete’s sport
the body part that is injured
information about how the injury or accident occurred
whether the injury is a new or previous one
AT’s thoughts about the injury and signature

Treatment Records

Any treatment an athlete received such as –

ice or heat application, elastic wraps
stretching, strengthening
splinting
medical referral

Rehabilitation Charts

injury assessment
recommended rehabilitation programs
specific treatment provided to the athlete and the date
problems or complaints or any changes in treatment
athlete’s response to the treatment and re-evaluation data

Patient Encounters

interactions with the patient when providing athletic training services
written, verbal, or electronic communication with any relevant individual or entity

ATs also use diverse injury-tracking systems such as Athletic Trainer System (ATS), SportsWare, Sports Injury Monitoring System (SIMS), SimTrack, NCAA, and Presagia Sports that store and provide valuable information such as demographics, injury report, progress notes, medication log, insurance information, exercise flow sheet and more.

The National Athletic Trainers’ Association (NATA) recommends that ATs be aware of the documentation needs specific to their setting and comply with all state regulations, established guidelines, and institutional requirements/expectations. Leveraging EMR-integrated medical transcription services is a reliable way for ATs to maintain compliant, accurate and complete documentation that can be securely shared with patients and other clinicians.

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Guidelines And Tips For Medical Records Management

06-September-2021 Rajeev Rajagopal Medical Transcription

Medical Records

Consistent, accurate, complete and up-to-date medical records are vital for proper health care delivery and continuity of care, as well as for insurance, legal, and other purposes. The healthcare provider’s responsibility includes managing the records of current patients as well as retaining old records to meet potential needs, and providing HIPAA-compliant remote access to patient information by a third party vendor like a medical transcription company.

Basic Functions Of The EHR

EHRs contain extensive information generated as a result of patient care:

Patient demographics
Progress notes
Vital signs
Medical histories
Diagnoses
Medications
Immunization dates
Allergies
Radiology images
Lab and test results
Administrative and billing data

An EHR contains information from all clinicians involved in a patient’s care and is designed to allow access to this information by physicians, healthcare facilities, and other organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics. Today, patients too can access their medical records. Medical transcription outsourcing plays a key role in helping healthcare professionals maintain good electronic health records (EHRs).

Management Of Medical Records – Key Considerations

Proper medical record-keeping is a vital part of maintaining professional values and standards.

Legibility: All entries, whether digital or handwritten, must be legible and allow for a meaningful review by another provider involved in the patient’s care. Physicians need to be especially vigilant about this as some template based EHR systems can create a lot of irrelevant data that can be hard to interpret. A new study published in Sage Journals suggests that personalized readability formats (PRFs) could improve readability of medical passages in EHRs by 15% while maintaining comprehension.

Date and Signature: All entries in the medical record should be authenticated by the provider along with the date and time. The signatures can be handwritten or an electronic signature, but should be legible. CMS also instructs that late signatures should not be added to the medical record, unless they occur from the delay caused waiting for transcription to be complete. Medical record entries completed by a scribe or medical transcription service provider must be signed and dated by the treating physician’s/non-physician’s (NPP).

Timely Entries: All services provided to beneficiaries are expected to be documented in the medical records in a timely manner. CMS guidance on this is as follows: “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

Confidentiality: The American Medical Association clearly states that physicians have an ethical obligation to manage medical records appropriately in keeping with the professional responsibility to safeguard the confidentiality of patients’ personal information. Compliance implies adhering to HIPAA security measures which include:
- Establishing a clear policy prohibiting access to patients’ medical records by unauthorized personnel
- Limiting access to facilities where records are stored
- Identifying and proactively protecting patient records against anticipated security threats
- Training the organization/practice workforce on medical records security procedures
- Implementing technological security tools for protecting electronic health information
Record Retention: Facilities should use medical considerations to determine how long records have to be retained. For instance, immunization records should be kept indefinitely as also records of key health events, conditions or interventions that can impact the patient’s care in the future.

Make Medical Records Available: Medical records should be made available as requested or authorized by the patient or the patient’s designated representative and also to other physicians involved in the patient’s care, and the succeeding physician or authorized individual when the physician discontinues his or her practice. HIPAA permits covered entities to share protected health information (PHI) with third-party vendors such as independent medical transcriptionists, pharmacy benefits managers, claims processors, consultants, and other organizations called business associates (BAs). However, when outsourcing medical transcription or administrative work, it is critical for healthcare entities to choose a BA that meets HIPAA regulations.

Corrections and Amendments to Records: If an error is made in a medical record entry, the mistake should be handled in the right way. Physicians need to know what they can and cannot do with regard to making changes in the EHR. The original entry must not be deleted, and it should be possible to access the inaccurate information. The reason for the correction must be indicated, and the amendment must be dated and signed by the person who made the changes. Click here to learn about best practices for amending EHR documentation.

The best way to maintain complete, accurate and concise medical records is to document the patient encounter in real-time, or shortly afterward.

What Are The Turnaround Times For Different Types Of Patient Care Reports?

02-September-2021 MTS TEAM Medical Transcription

Patient Care Reports

As a physician, you know that electronic medical records (EMRs) store a variety of reports, including history and physical exams, operative reports, discharge summaries, inpatient progress notes, consultations, and radiology reports. It’s crucial for your healthcare organization to focus on ensuring accurate, timely, and complete clinical documentation. You might find that medical transcription outsourcing is a practical strategy for your medical practice. It ensures accurate EMR documentation from audio files of your dictation with a fast turnaround time (TAT). TAT plays a critical role in clinical documentation because it impacts your medical practice’s workflow efficiency, data capture, clinical decision-making, and patient care. TAT for different types of medical reports can vary.

The Centers for Medicare & Medicaid Services (CMS) require that services provided in an office setting be documented promptly to maintain an accurate medical record. While CMS does not define a specific time frame for this requirement, some Medicare claims processing companies have established a reasonable window of 24-48 hours. Healthcare professionals should adhere to this guideline and ensure that clinical documentation is completed promptly. Medical billing staff and coders must also be aware of the timeliness of medical record completion (www.capphysicians.com).

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Timeframe Guidance for 5 Common Medical Reports

Discussed below are the timeframe recommendations for 5 common types of medical reports.

History and Physical (H&P): According to Joint Commission PC.2.120, a hospital is required to “define in writing the time frame(s) for conducting the initial assessment(s)” and an H&P examination has “to be completed within no more than 24 hours of inpatient admission”. While the timeframes under which the result should be made available is not specified, standard IM.6.10 specifies that “the hospital has a complete and accurate medical record for patients assessed, cared for, treated, or served” and requires a “policy on the timely entry of information” (perspectives.ahima.org). The Joint Commission, however, stipulates when an update to the H&P is required: “when a history and physical (H&P) is completed within 30 days PRIOR TO inpatient admission or registration of the patient, an update is required within 24 hours AFTER the patient physically arrives for admission/registration but prior to surgery or a procedure requiring anesthesia services”. Other points highlighted by the Joint Commission:
- The term ‘registration’ generally refers to patients scheduled for same-day or outpatient procedures.
- The 24-hour timeframe begins when the patient arrives at the physician’s office for admission/registration.
- If the H&P is completed greater than 30 days prior to inpatient admission or registration, it cannot be updated. A new H & P must be done.
- A properly documented H&P is valid for the entire length of stay. All changes to the patient’s condition should be entered in the daily progress notes.
- A new H&P or update to the H&P is not required for a patient who remains continuously hospitalized. If the patient has been discharged and later readmitted, a proper H&P (no greater than 30 days) would be needed and it should be updated within 24 hours after re-admission/registration but before a surgical procedure or other procedure requiring anesthesia.

Operative Reports and High-risk Procedure Reports: You should dictate and document these reports immediately after the operative or other high-risk procedure. The goal should be to ensure that pertinent information is available to the next caregiver. The Joint Commission’s notes on operative reports are as follows:
- Immediately after surgery or procedure’ implies “upon completion of the procedure, before the patient is transferred to the next level of care”.
- The report can be written or dictated by the surgeon in the new unit or area of care the patient is shifted to after the operation.
- In case the progress note option is used, it must include, at a minimum, comparable operative/procedural report information.

Discharge Summaries: A discharge summary documented by a medical transcription service provider typically consists of components, such as the reason for hospitalization, significant findings, administered procedures and treatments, the patient’s condition at discharge, and instructions for both the patient and their family. According to AHIMA, all of these records must be brought together, reviewed, and completed within 30 days of discharge, unless state law dictates a different time frame. Other time-related elements for a discharge summary:
- The record should be removed from the nursing station as soon as possible after discharge within 24 – 48 hours, but no more than 72 hours after discharge.
- The initial assembly and analysis should take place within 5 days of discharge.
- The remaining time should be used to follow up on gaps and track documents that are mailed for completion and/or signature so that the discharge record can be completed in a timely manner.
Progress Notes: Best practice to complete your charts promptly after treatment while the information is still fresh. Progress notes should ideally be finished within 24 hours of the appointment. Progress Note Float is the length of time between when a treatment visit takes place, and the progress note is completed, signed, and available for billing (www.10e11.com). Progress note “float” can be the result of:
- Over-scheduled physicians who do not have enough time to complete their progress notes.
- Alert fatigue when supervisors are flooded with alerts to sign a note and ignore them in favor of doing other work.
- No official rule or process enforced to complete progress notes.
- Lack of technology, leading to papers being shuffled back and forth and delays in communication.

Facilities need to create their own policies regarding the timeframe for completing progress notes.

Radiology Reports: Radiology report TAT is a commonly used metric to evaluate radiologist efficiency since the imaging report is the primary means by which diagnostic interpretations are conveyed to referring clinicians. Quick TAT is especially crucial for reports on patient care provided in the emergency department. Timely imaging reports can aid referring physicians in making informed decisions about treatment plans and delivering prompt care. According to an article in Radiology Key, TAT may vary among stakeholders, with referring clinicians considering TAT as the time from when a diagnostic imaging study is ordered until the results are received, while radiologists typically view TAT as the time from when a study is complete and available for interpretation until final signature. The utilization of voice recognition and structured reporting has been found to enhance radiology report TAT and reduce errors. In a study of medical transcriptions, a majority of respondents reported a contracted TAT for electronic documents of 10 hours.

Efficient Medical Report Timeframes

Delaying clinical documentation can result in serious consequences. Under California Business and Professions Code § 2266, physicians who fail to maintain accurate and adequate records regarding the services provided to their patients may be considered to have engaged in unprofessional conduct.

Fortunately, the adoption of EHR systems, speech recognition software, and the availability of outsourced medical transcription services is helping healthcare providers meet the turnaround time requirements for patient notes. If you are considering outsourcing, you should know that leading US-based medical transcription companies employ skilled medical transcriptionists. With proper knowledge of medical terminology, they can ensure high accuracy rates and deliver transcripts from audio recordings of physician dictation to meet your specific TAT. Partnering with a service provider can assist you in providing safe and timely treatment and care while mitigating the risk of malpractice claims and allegations.

Outsourcing your medical transcription to us can ensure accurate and timely EHR documentation.

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Structured Vs Unstructured Radiology Reporting

30-August-2021 Julie Clements Radiology Transcription

Radiology Reporting

The radiology report is the main and often only means of communication between referring physicians and radiologists. Traditional radiology reporting involved a trained radiologist dictating the findings of a radiologic study or procedure and its documentation by a radiology transcription service provider. These reports were unstructured, varying greatly in style and format. Today, referring physicians prefer structured radiology reports. Recent reports say that artificial intelligence (AI) is helping radiologists to identify valuable information and produce reports that physicians will understand more quickly.

Radiology reports serve multiple purposes and convey various types of information:

the type of test that was performed and the valid reasons for it
the findings, both negative and positive
a general impression or differential diagnosis, and
the radiologist’s recommendations for additional diagnostic evaluation and management

Drawbacks of Unstructured Radiology Reports

The Radiological Society of North America (RSNA) is focused on improving the organization, content, readability, and usefulness of the radiology report and to enhance the efficiency and effectiveness of the reporting process. Conventional imaging reports dictated by radiologists are unstructured and describe everything in detail, the idea being that nothing should be left out. This unstructured reporting format has many drawbacks:

Errors in dictation lead to inaccurate transcripts and radiology reporting
Even if unstructured reports contain clinically relevant information, they are unorganized as have no predefined format
It is difficult to retrieve data from these reports if the language used is difficult to comprehend
The inherent inconsistency of unstructured report content may lead to loss of pertinent information
Such data cannot be used for quality-based or evidence-based medicine analysis
The reports may not be available promptly.

Structured radiology reporting has the potential to address many of these concerns.

Advantages of Structured Radiology Reports over Conventional Text-rich Reports

The objective of structured radiology reporting is to standardize the format and vocabulary used in reporting. Structured reporting templates in electronic medical records provide consistency and clarity, allow prompt entry of all critical data elements, and enable scalable data capture, interoperability, and exchange. Structured reports have the potential to:

Provide clear, correct, complete and effective communication of imaging results
Reduce uncertainty and misunderstanding via the use of a standard lexicon in reporting
Reduce the rate of errors in reporting and communication
Facilitate locating or interpreting key aspects of what a radiologist has reported
Make it easier for referring physicians, billing and coding specialists, medicolegal representatives, and researchers to identify and compare information from radiologic reports

Structured reporting using speech recognition (SR) saves time in dictation, creates accurate, user-friendly multi-media reports quickly, makes difficult case easier to understand and improve turnaround time (collaborativeimaging.com).

Downsides of Structured Radiology Reports

While structured reporting offers many benefits and are the widely accepted solution for organized radiology reports, they have certain downsides too. Collaborative imaging lists these drawbacks as: reporting monitoring reducing focus on image study, depriving structured reports of descriptive qualities, non-availability of imaging lexicons, and duplication of medical records if electronic patient records have not been incorporated into structured reporting systems.

SR and AI are Improving Unstructured Radiology Reports

Speech recognition and artificial intelligence (AI) are advanced tools that are promoting data driven workflows in radiology. Integrating artificial intelligence (AI) with radiology reporting workflows – radiology information system (RIS) and picture archiving and communication system (PACS) – can optimize patient management.

The good news is that artificial intelligence (AI) is helping to organize unstructured reports. Imaging Technology News (ITN) recently reported on the Nuance PowerScribe Follow-up Manager, an AI-powered tool that automates follow-up tracking and compliance by:

Identifying follow-up recommendations by analyzes unstructured text, words, phrases, and data in existing reports using advanced language understanding
Automatically tracking the recommendation to ensure the exam is completed within the prescribed timeframe.
Proactively alerting the referring physician or patient if the needed exam is not completed in time to ensure it is performed.

Physician notes and radiology reports in EMRs may contain ambiguous words and narrative sentences. By converting this unformatted, unorganized data into blocks of specific information, for e.g., the type or extent of disease, AI is promoting productive radiology and better patient care.

The future of radiology reporting obviously lies in AI-powered diagnostic models, natural language processing, and clinical analytics tools. As Imaging Technology News explains, “These advanced technologies can drive continuous quality improvement and provide a collaborative, value-based framework for providers, payers, and other stakeholders to use radiology data to optimize and reward high-quality practices and promote value-based care”. Radiology transcription services will continue to play a significant role in ensuring the quality of radiology reports.

What Are The 5 Key Rules Of HIPAA?

26-August-2021 Rajeev Rajagopal HIPAA Compliance

HIPAA

HIPAA or Health Insurance Portability and Accountability Act of 1996 focuses on protecting Protected Health Information (PHI). This law established national standards on how covered entities, health care clearing houses, and business associates share and store PHI. HIPAA-compliant medical transcription ensures that sensitive patient data remains confidential, preventing unauthorized access, use, or disclosure. Non-compliance can result in severe legal consequences, reputational damage, and compromise patient confidentiality. Practices must outsource only to HIPAA-compliant medical transcription companies to ensure safety and confidentiality of patient data. Outsourcing transcription tasks helps to minimize the burden on physicians related to EHR documentation. Ensure that the chosen transcription vendor is well aware of the regulations of HIPAA. By strictly following HIPAA guidelines, transcription services contribute to maintaining patient trust, safeguarding privacy, and upholding the integrity of the healthcare system.

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5 Key HIPAA Rules for a Medical Transcription Company

The following are the five main HIPAA rules to understand:

1. Security Rule: This rule regulates the standards, procedures and methods regarding the safety of electronic Protected Health Information (PHI) on storage, accessibility and transmission. There are three levels of security here which are as follows:

Administrative Requirements: These are rules that ensure that the patient data is accurate and accessible to authorized people. Following are its privacy procedures:
- Assign an executive to oversee data security and HIPAA compliance.
- Identify the employees that have access to patient data.
- Train employees about the privacy policy of your organization and how it applies to their job.
- Require all outside parties who need to access protected patient data to sign contracts stating that they will comply with HIPAA security rules.
- Back up data and keep an emergency plan ready in case of disasters that could cause information loss.
- Conduct an annual data security assessment.
- Develop a data breach response plan that addresses affected patients and resolving compromised IT systems.
Technical Security Requirements: These are measures that protect your networks and device from any breaches:
- Protect your sensitive files by encrypting them when sending them via email and make sure that any cloud-based platform you use has encryption.
- Authenticate data transfers to third parties with password, a two- or three-way handshake, a token, or a call back.
- Require that employees periodically change their passwords, and ensure passwords contain a mix of letters, numbers, and special characters.
- Protect your network from any kind of hacking and other breaches with firewalls and intrusion detection systems.
- Train your employees so that they can identify and avoid phishing scams.
- Prevent data entry mistakes by using double-keying, checksum, and other redundancy techniques.
- Keep updated documentation of your organization’s technology and network configurations.
Physical Requirements:These rules help your organization prevent physical theft and loss of devices that contain patient information.
- Limit patient access to computers by keeping them behind counters, secured to desks, and away from the general public.
- Restrict access to secure areas, monitor building safety, and require visitors to sign in.
- Be cautious and follow best practices when upgrading or disposing of hardware and software, or even when securely wiping hard drives.
- Train employees and contractors about physical safety best practices, and make them understand the importance of securing their cell phones and mobile devices.

2. Privacy Rule: It protects the PHI and medical records of all the patients. It also limits and has conditions on different uses and disclosures that can be and cannot be made without the authorization from the patients. This rule permits the patients to have a copy of their records and also request for corrections to their file. Request of Access to Protected Health Information (PHI); Notice of Privacy Practices (NPP) Form; Request for Accounting Disclosures Form; Request for Restriction of Patient Health Care Information; Authorization for Use or Disclosure Form; and the Privacy Complaint Form are some of the specific forms that concur with this rule.

3. Identifiers Rule: There are three unique identities that HIPAA identifies for those who use HIPAA -regulated financial and administrative transactions, National Provider Identifier (NPI), a 10-digit number used for covered healthcare providers in every HIPAA administrative and financial transaction, National Health Plan Identifier that identifies health plans and payers under the Center for Medicare & Medicaid Services (CMS), and the Standard Unique Employer Identifier which identifies employer entity in HIPAA transactions.

4. Enforcement Rule: This is an extension of HIPAA Privacy and Security Rule that increases the penalties in case of any violation. This rule focuses on five areas, and is relevant to covered entities and business associates:

Application of HIPAA security and privacy requirements
Establishment of mandatory federal privacy and security breach reporting requirements
Development of new privacy requirements and accounting disclosure requirements and restrictions on sales and marketing
Establishment of new criminal and civil penalties, and enforcement methods for HIPAA non-compliance
A stipulation that all new security requirements should be included in all Business Associate contracts.

5. Transactions Rule: This rule deals with the transactions and code sets used in HIPAA transactions. It includes ICD-9, ICD-10, HCPCS, CPT-3, CPT-4 and NDC codes, and these codes should be used accurately to ensure accuracy, safety and security of medical records and PHI.

HIPAA Rules

Outsourcing to HIPAA-compliant Medical Transcription Service

While outsourcing the transcription task, it is important for healthcare organizations to ensure that the chosen transcription vendor is well aware of the regulations of HIPAA.

Following are some of the measures that medical transcription services take to be HIPAA compliant.

All transcription files that contain vital healthcare information are encrypted, so that only authorized personnel can access the files.
All medical transcriptionists are made aware of non-disclosure and privacy agreements before taking up the project, and the transcription work begins only after the required clearance.
No external subcontractors have access to transcription files or handle medical transcription.
It is ensured that all networks are protected with internal transcriptionists and use of password-protected computers. The software is also protected with the latest anti-virus programs.
Regular technical assessment is done to make sure that all the security systems are working seamlessly.
Damaged/unwanted or duplicate medical records are shredded immediately.
The premises have maximum security with 24/7 security personnel.

A medical transcription outsourcing provider with long-term experience in the field will make sure that all healthcare data entrusted to them remain private and confidential. Healthcare providers looking to utilize transcription service must take special care to understand the various security and confidentiality practices of their partnering agency.

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How Medical Transcription Services Quicken Pre-hospital PCRs

19-August-2021 Julie Clements Medical Transcription

“If You Didn’t Write It On Your Patient Care Report, You Didn’t Do It.”

Medical Transcription Services

The patient care report (PCR) is an essential document that conveys prehospital patient and demographic data to the emergency department or other hospital-based healthcare provider. Even as paramedics respond to emergency calls and provide emergency care on route to the hospital, they need to ensure accurate and timely prehospital PCRs for the emergency physician. The emergency department can make further treatment decisions based on the outcomes of treatments noted on the PCR. The best way for paramedics to ensure clear, complete, precise, and timely patient care reports is to rely on an experienced medical transcription service provider.

Purpose of the Prehospital Patient Care Record

To serve as a medical record
To provide a precise picture of the events that occurred
To ensure standards of care were met
For quality assurance and performance improvement
To bill government and private insurance
For use in litigation

There are different PCR formats and special reports would be needed for disasters. Paramedics should use the format specific to their organization’s needs and provide a comprehensive and pertinent account of the events leading up to the patient handover to the hospital.

Importance of Accurate and Timely Prehospital PCRs

By documenting their initial assessment, the paramedic provides an overall picture of the patient’s status at the time of their arrival on the scene. This initial evaluation of the patient helps support the medical diagnosis and basis for treatment decisions. In addition to documenting the assessment, each intervention performed by the paramedic and the rationale for it should be properly documented.

The information should be clear and concise documented so that the emergency physician and other healthcare professionals can easily understand it. Accurate, complete, and easy-to-read documentation can help guide the care plan and further treatment. Detailed and accurate prehospital documentation is also necessary to secure reimbursement the patient care services and transport to the hospital. Also, if an EMS provider is called to testify in a court of law, complete and accurate documentation can help to defend the provider.

Prehospital PCRs – Problems Reported

While it is an essential tool for ED handovers, many problems have been reported with prehospital PCRs. A 2015 report in the Journal of Emergency Medical Services (JEMS) references John Riccio, MD Medical director for South Metro Fire/Rescue in Centennial, Colorado, as saying that while he was sure that paramedics were providing proper care, a review of the PCRs they created were rife with problems. To quote from the article, “Treatments were entered out of order, some narratives offered only a brief paragraph, and assessments were so full of abbreviations that the reader needed a medical dictionary to understand them. Misspelled words and poor grammar made even smart paramedics look bad, but the problem wasn’t just mistakes by the crew. A lot of the difficulty came from the format of the reports; important information was often buried in long lists, but not included in the narratives where most healthcare professionals put them.”

Studies on PCRs have also reported many concerns. A study published in the West J Emerg Med. in 2013 reported that most electronic prehospital PCRs were not available at the time of ED medical decision-making. Further, though handwritten prehospital PCRs were more readily accessible, they had legibility and accuracy concerns.

Medical Transcription Services to the Rescue

The reports that a medical transcription company provides from physician dictation include consultation reports, client medical history reports, physical exam reports, emergency room reports, operative reports, laboratory reports, radiology reports, pathology reports, and discharge reports. They can also provide transcripts of dictated prehospitalization reports. The JEMS article reported how paramedics benefited from medical transcription. South Metro experimented with U.S. based medical transcription services to document their paramedics’ dictation and found that it considerably improved the accuracy and timeliness of prehospitalization PCRs.

The information in a prehospital patient care report generated by a medical transcriptionist would generally include the following:

Patient demographics (name, address, date of birth, age, and gender)
The location of the call and time of the call
Names of rescuers and first responders on the scene
Data related to patient care related data – patient’s chief complaint, provider’s initial impression of the patient, evaluation, status and vital signs of the patient during ambulance transport, interventions done, and responses to those treatments

Outsourcing medical transcription can also help the paramedic clearly communicate the message to the emergency physician. According to ems.com, paramedics should ensure:

Legible documentation with no spelling errors
Use only approved medical abbreviations
Double-check demographic data
Use a consistent system to track time and document travel times, treatment times, and changes in condition
Document what they see and hear (and smell, if necessary) throughout the call
Report statements made by others about what happened prior to their arrival.
Provide a detailed chronological narrative of the call from the beginning to emergency room.

Good documentation takes time and paramedics may find it difficult to find that time. With professional medical transcription services to assist them, paramedics can ensure highly accurate reports every time.

How Medical Transcriptionists Preserve The Integrity Of The Medical Record [INFOGRAPHIC]

12-August-2021 MTS TEAM Infographics

Even in this the age of electronic health records and speech recognition systems, human medical transcriptionists (MTs) still have a significant role to play in the healthcare system. They convert the physician’s dictated report into text format and highlight discrepancies for correction. Though this may sound relatively simple and straightforward, there’s more to it. With computerized audio-to-text conversion by speech recognition software, MTs have a crucial role in editing the results. They make the necessary corrections by reviewing the text while listening to the original audio file to ensure accurate capture and formatting of the content. However, to ensure error-free transcription with proper formatting and grammar correction, rely on a skilled medical transcription service provider. They will ensure that the physician receives an accurate, timely, and secure record.

Check out this infographic to know how MTs preserve the integrity of the medical record:

Medical Transcriptionists