Best Approaches for Documenting Allergies in the Electronic Health Record

09-August-2021 Julie Clements EHR Transcription

Electronic Health Record

Patients’ adverse reactions to medications and allergies to food and other substances are an important component of documentation that medical transcription service companies specializing in allergy and sleep medicine transcription can help physicians like yourself with. It is important to document a complete and accurate allergy history for each patient. Accurate and timely documentation of allergies in electronic health records (EHRs) is critical for you to be better prepared for adverse events and ensure proper care.

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The Joint Commission and the Accreditation Association for Ambulatory Health Care (AAAHC) require providers to document drug allergies and their reactions in a “highly visible location in the patient’s chart”. The Centers for Medicare and Medicaid (CMS) also require documentation of patient drug allergies and associated reactions in the Conditions for Coverage section.

joint commission

The Agency for Healthcare Research and Quality’s (AHRQ) has stated that all health care professionals involved in a patient’s care should have the ability to record both drug allergies and adverse drug reactions. Only clinicians with direct knowledge of the patient should be permitted to change these labels and discuss any potential change in assignment (allergy vs adverse drug reaction) directly with the patient before the change is made.

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Best Practices for Documenting Allergies in Patient Records – what Physicians and Allergy and Sleep Medicine Transcription Providers Should Know:

Create an Accurate Record of the Patient’s Allergy History: You should discuss allergies with your patients at each visit and correctly record existing or new allergies and reactions. A Relias media article references Belle Lerner MA, director of research at the AAAHC Institute for Quality Improvement as saying that these discussions are also important to understand if the patient has an allergy or a COVID-19 symptom. The key is to get as much information as possible from the patient.

Educate Staff: Practice staff must be educated about all types of allergies, including food, latex, mold, and drugs as well as symptoms and what to look for. Typical drug allergy reactions include: skin rash or hives, itching, wheezing or other breathing problems, swelling, and anaphylaxis, a reaction that can affect two or more organ systems and be potentially life-threatening. Staff should also be trained to handle adverse events properly.

Ensure Consistent and Up-to-Date Patient Documentation: Lerner points out that documenting the type and severity of reaction is essential for crucial allergy decision-making. Make sure the documentation includes all prescription medications and supplements as well as over-the-counter vitamins, medications, and supplements. Drug allergy status should be documented in all communication regarding the patient between health care providers.

Medication Reconciliation: Comparing a patient’s medication orders to all of the medications that the patient has been taking or medication reconciliation can avoid errors such as medication omissions, duplications, dosing errors, or drug interactions. Best practice is to do this at every care transition during which new medications are prescribed or existing orders are rewritten.

Standardize Procedures: Documentation of a drug allergy in the patient record should include the reaction, the drug administered, the timeframe of the reaction from when the drug was given, and the drugs to avoid. EHRs can include prompts alerting patients to provide updated allergy information to their pharmacy, which can minimize confusion. If medications are ordered in the surgery center, surgery staff should share all allergy documentation and information with the primary care provider and the pharmacy. This crucial for smooth transition of care.

Despite the importance of good allergy documentation, the Agency for Healthcare Research and Quality (AHRQ) reported that the majority of EHR allergy modules have serious drawbacks when it comes to documentation allergies and triggering drug allergy alerts.

Limitations of the majority of EHR allergy modules include:

Frequently missing documentation of reaction mechanism and type
Absence of a comprehensive terminology
Lack of adequate tools for reconciling allergy information, and
An allergy alert override rate of greater than 90 percent caused by physician alert fatigue

The AHRQ project to improve allergy documentation and clinical decision support in the EHR aims to provide clinicians at the intervention sites with access to an allergy reconciliation module in the EHR.

Correct and complete documentation is crucial to deliver patient care in a safe environment. As you focus on treating allergies, you can rely on a medical transcription company that provides allergy and sleep medicine transcription service to ensure timely and accurate documentation of allergies in the EHR.

Can Speech Recognition Support Emergency Department Documentation Goals?

05-August-2021 Rajeev Rajagopal Emergency Room Transcription

Speech Recognition

Accurate and timely emergency department (ED) patient records go a long way in supporting physicians in various aspects of care. Emergency room medical transcription service providers help physicians document all ED processes – from evaluation to medical decision making and patient encounters by disposition and treatment. In the busy ED environment, many physicians rely on speech recognition (SR) to document dictation into the electronic health record (EHR). But how does SR impact ED documentation? Let’s take a look at what reports say about this.

Effective ED Charting – Objectives and Benefits

ED charts serve many purposes.

Charting allows ED physicians to inform other healthcare providers about what was done in the ED. This includes diagnostic tests, medical decision making, and treatments, as well as discussions with patients and their families, communications with consultants about recommendations, patient follow-up, and other aspects.
Proper ED charting supports accurate billing for appropriate reimbursement.
By showing what happened at the encounter ED charts provide medicolegal protection in the event of a lawsuit or patient complaint.
Good charting supports utilization management/risk management. Chart review is essential for quality improvement processes.
Good clear documentation can help researchers gather data and conduct studies that can help improve care.

According to the American College of Emergency Physicians (ACEP), effective ED medical record keeping helps with:

Documentation of clinically relevant aspects of the patient encounter including laboratory, radiologic, and other testing results
Efficiency in the patient encounter continuum
Legibility
Communication with other providers
Coordination of follow-up care
Identification of who entered data into the record
Discharge instruction communication
Ease of data collection and data reporting

(Reproduced from: https://www.acep.org/patient-care/policy-statements/patient-medical-records-in-the-emergency-department/)

Can Speech Recognition Promote Efficient ED Documentation?

High quality capture all aspects related to the patient encounter and medical decision making correctly and promptly, thereby promoting proper medical diagnosis and care as well as quality assessment and improvement, meaningful use, and risk management.

Using SR for note-taking is a popular option for its convenience, ease of use, cost-effectiveness, and efficiency at the point of care. But does using SR help ED physicians achieve these documentation goals? Researchers at Brigham and Women’s Hospital Department of Emergency Medicine in Boston conducted a study to answer this question. The research study, titled “Incidence of Speech Recognition Errors in the Emergency Department” which was published in the International Journal of Medical Informatics in 2017 reported that 71% of the notes transcribed using SR software contained at least one error.

Study author Scott Weiner, MD, MPH termed the adoption of SR software in the ED as a game changer. However, Weiner’s team found that SR use in the Brigham and Women’s Hospital Department of Emergency Medicine caused clinical documentation errors, some of which were serious. The study reported that:

Annunciation errors were the most frequent
There was at least one critical error in 15% of notes, which could potentially lead to miscommunication that could affect patient care

Weiner offered two possible explanations for SR-generated errors in ED documentation. The first is the drawbacks of the technology – it can lead to errors if the user’s speech is not clear or uses words that the software does not recognize. The second challenge relates to the hectic and noisy ED environment where interruptions of all kinds may make it difficult for the physician to ensure proper dictation and proofreading of documentation to spot mistakes. The study concluded that speech recognition technology could lead to miscommunication that could adversely affect impact patient care.

In 2020, researchers published a study “Physician use of Speech Recognition versus Typing in Clinical documentation: A Controlled Observational Study” in the International Journal of Medical Informatics. Conducted in the same setting, Brigham and Women’s Hospital, Boston, Massachusetts, this observational study reported that while clinicians use SR for electronic health record (EHR) documentation, the “usability and effect of the technology on quality and efficiency versus other documentation methods remains unclear”.

Errors in ED documentation can be avoided if clinicians using SR are aware of its limitations and proofread their notes carefully. However, in the chaotic ED setting, this is often impossible. Outsourcing medical transcription is a viable solution to this problem. Providers of emergency department medical transcription services have expert teams to carefully proofread SR-generated transcripts after which they can be sent back to the dictating physicians for review and signed approval. This strategy can go a long way in ensuring high quality ED documentation to promote improved patient care.

New Federal Rule gives Patients Free Electronic Access to their Medical Notes

02-August-2021 MTS TEAM EHR Transcription

Medical Notes

Health reports dictated by healthcare providers are converted into written documents by US based medical transcription companies and include history and physical reports (H&P), progress notes, consultation reports, surgery notes, discharge summaries, and more. As of April 2021, a provision of the 21st Century Cures Act requires healthcare providers to give their patients free access to their electronic medical record chart notes.

The United States Core Data for Interoperability (USCDI) lists 8 types of clinical notes that must be shared:

Consultation Notes
Discharge Summary Notes
H&P
Imaging Narratives
Laboratory Report Narratives
Pathology Report Narratives
Procedure Notes
Progress Notes

Studies have found that “shared visit notes” improve patient-provider communication and enhance the quality and safety of health care. According to the OpenNotes initiative, patient-reported benefits of reading their visit notes include:

Better understanding of their health and medical conditions
Can remember their treatment plan more correctly
Are better prepared for visits
Experience more control over their care
Take better care of themselves
Better medication adherence
More involvement in their own health and care through proactive conversations with their clinicians

Sharing notes also improve medical record accuracy as patients can alert their physician if they notice errors in the notes. Studies also report that open and honest communication can help decrease litigation risks. It can also reduce caregiver anxiety and stress allowing them to view the physician’s observations on the patient’s presentation, diagnoses, prognoses and treatments being considered.

Clinician Concerns about Patient Access to Medical Records

The effects of open notes have been studied for years. Earlier, physicians had many concerns about sharing visit notes with patients. One concern is that patients may feel confused or distressed when they read the notes. They would find it difficult to understand complex language, medical jargon, abbreviations, acronyms and pejorative terms in medical notes.

Another concern is about the use of such as ‘obesity’ or ‘overweight’, which patients tend to find offensive. Heather Gantzer, an internist in Minnesota and recent chair of the board of regents for the American College of Physicians notes that obesity is a “really painful, painful word” for some people (Stat News, June 18, 2021). She opts to use objective terms such as a numerical BMI instead.

Writing more transparent notes can be more challenging if the patient has multiple psychological symptoms without organic disease, or in a malingering patient, notes David Blumenthal, MD in an article in The Rheumatologist. Physicians are also pondering about issues such as maintaining privacy for teenagers when their parents can access their notes. Moreover, if patients can see their test results before hearing about it from their doctor, it can end up being very distressing for them.

So how can clinicians overcome these concerns with open notes becoming the rule? Here are some expert recommendations that can help physicians successfully manage the transition to open notes:

Ensure Clear and Organized Notes: While the new law requires providing patients with timely access to notes and test results, it does not require that clinicians change their writing. However, physicians need to focus on creating patient-friendly notes that help patients find important information, and promote patient education and engagement. Being brief and using direct, simple language with less abbreviations or medical jargon, can avoid confusion for patients and for other physicians. Medical terms can be explained briefly, where necessary. Using a conversational style can help when in doubt (www.medscape.com).
Avoid Subjective Comments: Physicians need ensure accurate and objective in their reporting. This also means avoiding labels and using descriptive words. Subjective comments can lead other physicians or anyone else reading the notes to form an opinion of their own, which may not be correct. The goal should be to create a candid note that tells the reader exactly what is going on with the patient.
Use Language that Drives Positive Changes: Physicians need to focus on writing the medical record in a way that encourages patients to make positive changes, just as they would do in conversations during the office visit. Being less critical, avoiding bias, and showing appreciation for the patient’s accomplishments in one way of doing this. Providing a clear follow-up plan can prove reassuring for patients who are overwhelmed or feel worried.
Make Patient Portals Easier to Use: It would also be helpful to patients if existing portals are made easier to use. Mobile patient portals can improve the level of engagement for patients who may prefer to access their notes and manage their health using a smartphone and other mobile device. Creating platforms that link to educational materials and trusted content can help patients understand their medical record/condition more easily.
Encourage Patients to Read their Medical Notes: When patients, families and caregivers review notes, they may be encouraged to ask for clarifications and follow mutually agreed-upon treatment plans. This can also help them identify clinically important inaccuracies, which can be corrected or edited by the provider using the right mechanisms. According to Liz Salmi, senior strategist at OpenNotes, patients who have serious or chronic conditions are more likely to read their notes (www.medscape.com). As they are technically savvy, younger patients are also more likely to read their medical notes. It is believed that patients who are less educated, and have poor health literacy and poorer self-reported health are not likely to view their notes.
Know Information Blocking Exceptions: Exceptions to the Interoperability and Information Blocking Rule allow providers to block information in the patient portal in certain complex situations. Also, the rules do not apply to psychotherapy notes that a mental health professional records for documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session.

With Open Notes, physicians need to ensure accurate records that improve patient safety. Partnering with an experienced medical transcription company is the best way to do this and ease the EHR documentation task.

How To Properly Document Patient Medical History In A Chart

29-July-2021 Julie Clements Medical Transcription Company

Patient History

The history and physical (H&P) is one of the most important notes that medical transcription companies help family practice physicians include in the electronic health record (EHR). The H&P is critical for the physician to postulate the diagnosis when seeing the patient for the first time and order investigations to confirm it. Subsequent visits may only require a review of the medical history and updates to it. The H&P to provide medical authorization for surgery must be completed and documented at least a week before the scheduled operation. If emergency surgery is needed, the surgeon should have the document in hand before the patient reaches the operating room.

Medical history typically includes the following:

Presenting complaint and history of presenting complaint, including tests, treatment and referrals
Past medical history – diseases and illnesses treated in the past
Past surgical history – operations undergone including complications and/or trauma
Family medical history – chiefly of parents, siblings and children – which can be a genetic predisposition to a particular disease
Social history – alcohol, smoking, recreational drug use, accommodation and living arrangements, marital status, baseline functioning, occupation, and so on
Allergies, and current or past medications.
Review of systems: respiratory, cardiovascular, gastrointestinal, musculoskeletal, genitourinary, and nervous system

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The history is the key component of patient assessment and regarded as the most important part of the patient-physician interaction. Generally, the history alone can provide most of the information about the patient. Diligent history-taking at a clinical encounter could help prevent patients from re-presenting with disastrous outcomes caused by missed diagnoses.

Tips to Improve Patient History-taking

Here are some expert tips to improve patient history-taking:

Build Rapport with the Patient and Communicate Well: The main goal of taking the history is to identify the patient’s problem and care priorities so that proper interventions can be recommended. “A good history is one which reveals the patient’s ideas, concerns and expectations as well as any accompanying diagnosis”, notes an article on www.patient.info. To get the patient talking, the healthcare provider needs to make them feel comfortable by building rapport with them. For instance, asking patients about social history aspects like work or lifestyle can help build understanding. Telling the patient about the purpose of the conversation would encourage them to provide focused information. When patients are at ease, they are likely to provide important information. A good history is one that throws light on the patient’s ideas, worries and expectations along with any associated diagnosis.
Allow the Patient to Speak Initially: A 1984 study revealed that interrupting the patient early in the encounter and then reverting to closed questions often led to nondisclosure of relevant details by the patient (onthewards.org). It was found that when patients could complete their opening statement, more medical issues came to light. Letting the patient speak would make them feel that they have been heard and make it easier for the physician to move on to getting the history. The physician should ask the patient about their key concern so that it can be addressed.
Listen: Actively listen to the patient’s story. Instead of asking a barrage of questions to obtain information about the patient’s condition, physicians need to listen attentively to what the patient has to say. This can help the physician better understand the patient’s experience of the illness and related matters.
Get the Basic Information: This includes past medical history, medications, allergies, medications, and information about chronic conditions like diabetes and any complications. Additional details like the treating physician, last encounter and how well the condition is controlled should be included. Ethnicity, developmental history, pregnancy and fertility, travel history, etc. can provide important clues for diagnosis. For instance, the history of patients with fever and acute respiratory illness or other symptoms of COVID-19, should include information regarding travel history or exposure to a person who recently returned from a country or state experiencing active local transmission.
Be Flexible: Start with social history and past medical history before going into the history of presenting complaint, recommends an on the wards report. Knowing these earlier aspects of the history are important for establishing the probability of a condition before the investigation. It can also help with questions about the presenting condition and to make decisions about the testing.
Understand your Cognitive Biases: History taking is prone to cognitive biases such as Overconfidence, lower tolerance to risk, confirmation bias, anchoring bias, and information and availability biases. These ‘traps’ can lead to incorrect diagnosis and affect medical decision making. Physicians need to be aware of their cognitive biases and work to minimize bias-related errors.
Summarize the Information: Summarizing what the patient has said will help you better retain the information in your memory and ensure that you have understood it and the sequence of events.

Access to reliable family practice medical transcription services is important for physicians to maintain accurate patient records. Expert transcriptionists will format H&P reports and headings as required by the facility they are working for.

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Disclaimer – The content in this blog that is provided by Managed Outsource Solutions (MOS) is only for informational purposes and should not be seen as professional medical advice. MOS is only passing on information that is already published and does not accept any responsibility for any loss which may occur due to reliance on information contained in this blog.

Primary Care Physicians to Guide Post COVID-19 Care

26-July-2021 Rajeev Rajagopal Medical Transcription

COVID - 19

The Centers for Disease Control and Prevention (CDC) recently updated their interim guidance for healthcare professionals evaluating and treating post-v conditions. Despite the varied nature of these conditions, CDC staff has agreed that most of them can be diagnosed and managed by primary care physicians in a patient-centered medical home model. The patients should be examined in four stages, starting 4 weeks after a patient’s COVID-19 infection because some symptoms improve or resolve within 4 to 12 weeks.

According to Jennifer Chevinsky, MD, of the CDC, symptoms that last more than 3 months need specialist referrals or referral to multidisciplinary COVID-19 care centres. Chevinsky suggested a conservative diagnostic approach for the first 4 to 12 weeks. According to her, some patients may need diagnostic testing but lab tests may not distinguish post- COVID-19 conditions. Moreover, they are not required to diagnose post-COVID-19 conditions. If the symptoms continue for 12 weeks or more, additional testing may be considered.

There is no solid evidence on the utility of imaging for post- COVID-19 conditions, so Chevinsky noted that this should be guided by patient history and clinical findings. More advanced testing like cardiac MRIs may be done in consultation with a specialist.

Post COVID-19 condition of a patient can be improved using established evidence-based symptom management approaches to optimize function and improve the quality of life. Chevinsky pointed out that a comprehensive rehabilitation plan might be helpful for some patients. This plan does not include herbal remedies, supplements etc or any other treatment that patients may have used to treat their symptoms.

In ICD 10, there is as yet no code for post-COVID-19 conditions. So, the CDC has recommended documentation of these conditions using B94.8 (sequelae of other specified infectious and parasitic diseases).

Alexis Vosooney, MD of the American Academy of Family Physicians, emphasized the importance of confirming the patient’s experiences, which CDC also recommended in its guidance. She also requested clinicians to talk to the patients about their goals, whether they are looking for an “answer” to their symptoms, to get back to where they were before COVID-19, or whether they have a fear of another disease process. She also added that being transparent with the patient is important and admit that there isn’t much evidence about COVID-19 symptoms and recovery.

Another important aspect is that physicians should be able to distinguish between COVID-19 and other chronic diseases. For instance, shortness of breath need not be because of COVID-19, it could be asthma. Michael Saag, MD, of the University of Alabama at Birmingham, stressed the importance of differentiating between post-COVID-19 symptoms and post-intubation syndrome in patients who were on a ventilator.

Post COVID-19 conditions can be severe, mild or asymptomatic and it can happen to patients, from children to adults, and can be continuing, recurrent, or new symptoms can develop over time. In such cases, it is important to record all these symptoms because it helps physicians study and understand post COVID-19 conditions and how to provide optimal care.

As a company providing medical transcription services, we know how important documentation is in this regard. Accurate medical records are vital to study various medical conditions, treatments provided and patients’ response to those and the outcomes, and so on. The medical documentation should include complete details of the patient, and accuracy in patient records determines the quality of service provided to the patient.

Top Tips to Improve Medical Transcription Skills [INFOGRAPHIC]

22-July-2021 MTS TEAM Infographics

Speed and accuracy are crucial factors in medical transcription. Professional medical transcription services can ensure accurate and affordable clinical documentation solutions in the short turnaround time. Real-time transcription solutions allow healthcare teams to work with the updated patient health information. Following certain tips and tricks can help professional transcriptionists to gain an edge over the competition.

Check out the infographic below

Medical Transcription

Inpatients Face Delays in Endoscopy That Lead to Long Stays at the Hospital

19-July-2021 Julie Clements Medical Transcription

Endoscopy

Delay is something we all want to avoid, especially when it is something urgent. As a medical transcription service assisting healthcare providers, we are very much aware of this and ensure completion of our projects without delay. When it comes to providing healthcare services and treatments, promptness and speed are vital factors. Delay is something that can be quite distressing and harmful to patients.

One of the common issues patients frequently face is the long wait time for medical tests.Many patients experience fear, anxiety, and worry while waiting for these assays. According to a retrospective study published on MedPage,inpatient endoscopy delays resulted in extended hospital stays and readmissions within a month.Out of around 4000 inpatients treated at a tertiary care center for endoscopy, 19.3 percent of patients faced the problem of delays that led to additional hospital stay of 2 days on an average. Dennis Yang, MD, and colleagues from the University of Florida in Gainesville, who conducted the study,point out that 19.7% were readmitted within 30 days.

According to the findings in Clinical Gastroenterology and Hepatology, the major causes for delays in endoscopy were poor bowel preparation (27%), followed by the lack of endoscopic unit availability or personnel (24.4%). Independent predictors for endoscopy delay in inpatients included colonoscopy, being on contact isolation, and use of antithrombotics. The study authors noted that the results they got highlight the importance of triaging inpatients to the most appropriate service at the time of admission, as well as the value of a dedicated inpatient GI service limiting process delays, with improvement in patient flow for inpatient endoscopic services.

It is difficult to coordinate for endoscopies for inpatients due to several factors and the delays can lead to rise in costs due to extended hospital stays. Further, long period of stay could increase patients’ risk for nosocomial infections. To provide inpatients with high-quality healthcare, timely inpatient endoscopies are critical.

Eamonn Quigley, MD, of Houston Methodist Hospital, told MedPage that hospital endoscopy units must be flexible to accommodate the unpredictability of inpatient cases. Resolving these issues will help in shortening the length of stay and also minimize readmission rates. The results often come as a surprise and it is important to understand the challenges that are related to inpatient endoscopy.

Yang and colleagues conducted a comprehensive analysis of several factors in an attempt to mitigate inpatient endoscopy delay and allow patients quality healthcare access. Their study examined 4,239 inpatients in a tertiary care center whose documented endoscopy data was assessed from November 1, 2017 to November 31, 2019. The study was conducted to assess inpatient endoscopy delay frequency in a tertiary care center, including effects on 30-day hospital readmission and hospital length of stay.

The average age of the patients in the study was 58 and the most common reason for gastrointestinal-indicated admissions among patients were lower GI bleeding (20.8%), abdominal pain (18.9%), and anemia (6.8%). Older patients, mostly women, were the ones who experienced inpatient endoscopy delay. Inpatients who experienced delays had a greater chance of not having the cause of their disease identified during endoscopy. One limitation of the study was that data was unavailable for around 25% of study participants because of the retrospective design.

Delays in tests and long patient wait time lead to unhappy, dissatisfied patients who tend to leave the medical practice and may not return again. In the course of providing medical transcription service to physicians and other clinicians, we have come to know that the large majority of providers want to ensure that their patients receive timely care and attention without any delay. However, delays unfortunately occur due to various unavoidable reasons.Hospitals, clinics, and other healthcare facilities are therefore always implementing various measures and policies that would help avoid such delays and ensure patient satisfaction.

Key Tips to Write Better Mental Health SOAP Notes

15-July-2021 Rajeev Rajagopal Medical Transcription Outsourcing

An update to the blog, “SOAP Notes in Psychiatry – Features and Tips for Improvement”

Mental Health SOAP Notes

Writing comprehensive, concise and informative progress notes is crucial for providers to provide quality of care for patients further. Most providers use a pre-determined framework in their patient notes to improve the quality of documentation. When it comes to mental health or any other specialty, SOAP notes have become the gold standard in preparing progress notes. It is an efficient way of taking mental health progress notes. With more than 15 years’ experience in providing mental health transcription services, we are familiar with transcribing SOAP notes and any other psychiatry notes such as clinical notes, consultation notes, psychiatric evaluations, referral letters and discharge summaries.

What are SOAP Notes?

Expanded as Subjective, Objective, Assessment and Plan, SOAP framework serves as an ideal tool for healthcare professionals to document and communicate patient information. Though the method was used only by medical professionals in early days, it’s recognized today as an effective communication tool between providers of all healthcare disciplines to document a patient’s treatment.

The SOAP framework is one of the most commonly used methods for writing mental health progress notes, which help providers to capture the most significant information from a session using a clear, concise structure. This method enables practitioners of all specialties to communicate in a streamlined way and thus provide better care for each patient. The clear structure of SOAP notes also increases the accuracy of notes in general.

Hope you’ve read our blog that describes SOAP note structure in mental health.

Here are some key tips to effectively write better SOAP notes.

Choose the Right Time to Write

When to prepare progress notes is something you need to decide. During consultation with patients, providers may not get enough time to write their progress notes. During the session time, providers can take personal notes and fill out the SOAP framework later. Make sure to write the SOAP progress notes a few hours within the appointment on the same day, which prevents missing out on any key observations. Focusing on patients will allow gaining all crucial data which leads to quality patient care.

Write the Notes Right

Ensure that the notes you write are easily to follow for yourself as well as other professionals who may refer to them in the future. Focus on the tense used and avoid any confusion in pronouns. Edit the notes and do a simple spell-check and the notes must be detailed enough to provide sufficient information. Notes must include all sufficient information about the patient’s condition.

Keep the Notes Concise and Professional

Make sure to choose a concise writing style and keep the notes as short as possible. Collect some basic information along concurrent documentation, making it easier to strain the unnecessary information from the important information that need to be included in the SOAP note. Consider writing in formal language and avoid colloquialisms or any non-standard abbreviations that may affect the professional tone of progress notes. Maintain a professional tone, as the details will be clear for anyone reviewing them let that be fellow practitioners, attorneys or medical record reviewers. Shorten the content by cutting out unnecessary verbiage and lengthy descriptions. Remove wordy phrases, as it makes the notes more difficult to understand, mainly for other practitioners.

Keep Notes Error-free using Standard Procedure

Mistakes during progress notes preparation are quite common and so it is important to correct such errors with accepted procedures. Instead of altering the records with scratch-outs, eraser or deleting them, it is better to make corrections by striking through the mistake part and marking as error. By doing so, whoever uses the report can find the actual notes and corrected information.

Stay Neutral

Make sure not to include your own judgment in SOAP notes for mental health sessions. Instead, the notes should clearly describe situations that offer insight into the patient’s behavior. Never make any unsupported statements that come without evidence.

Following certain tips such as the above would make psychiatry note-taking process easier and increase clarity on what need to be included and not. To write notes in the SOAP framework, providers have to collect information from the patient on their conditions, review diagnosis results, gather information on signs of the condition and review notes from the patient’s last visit to determine whether the patient’s symptoms are getting better or worse.

Good progress notes make it easier for providers to track each patient’s progress over time and plan for future interventions, resulting in higher-quality care. Psychiatrists and psychiatry practices can rely on medical transcription outsourcing to get EHR-integrated transcription services for progress notes as well as any reports such as clinical notes, consultation notes, psychiatric evaluations, referral letters or discharge summaries.

Global Electronic Health Records Market to Register a CAGR of 3.7% during 2021-28

12-July-2021 MTS TEAM EHR Transcription

Electronic Health Records

According to a report from Grand View Research, the global electronic health records market size that was valued at USD 26.8 billion in 2020, is expected to witness a compound annual growth rate (CAGR) of 3.7% during the forecast period 2021 to 2028 and reach USD 35.1 billion by 2028. Electronic health records or EHRs are real-time, patient-centered records that make information instantly and securely available to authorized professionals. They also help improve patient care and streamline physician workflow. The introduction of EHRs also eased the medical coding and billing process for providers, as entering data into computerized systems is more convenient than other paper-based methods. EHRs also minimize the risk of errors in patient information and financial details. Most healthcare practices today utilize EHR-integrated medical transcription service provided by a medical transcription company to benefit from accurate EHR entry and reduced documentation workload.

Key factors that boost the growth of this market are –

Government initiatives to encourage healthcare IT usage
Introduction of technologically advanced healthcare services
Rising demand for centralization
Streamlining of healthcare administration
Increasing number of mergers & acquisitions by market players
increase in the demand for electronic health records due to the growing digitalization

The report segments the global EHR market on the basis of product, type, end-use, business models, and region. Product segment is further divided into client-server-based and web-based. The web-based EHR segment led the global market in 2020 and accounted for more than 54% share of the global revenue, and is projected to expand further at a steady CAGR from 2021 to 2028, due to the high usage of these systems by physicians. Types of EHR include acute, ambulatory, and post-acute. Due to the government initiatives promoting the usage of EHRs, the acute type segment dominated the market with a share of over 47% in 2020.

End-users of this market are – hospitals, ambulatory care, physician’s clinics, laboratories and pharmacies. Here, the hospital segment led the market and accounted for a market share of more than 61% in 2020. The ambulatory care segment, which includes physician clinics, laboratories, and pharmacies, is expected to exhibit the fastest CAGR over the forecast period, owing to the increasing number of ambulatory care centers globally. Business models include licensed software, technology resale, subscriptions, professional services and others. Of these, the professional services segment dominated the global market with over 30.0% share last year.

Region-wise, the market is divided into North America (U.S., Canada), Europe (U.K., Germany, France, Italy, Spain, The Netherlands, Sweden, Russia), Asia Pacific (China, Japan, India, Australia, Singapore), Latin America (Brazil), Middle East & Africa (South Africa, Saudi Arabia). Owing to the presence of well-established healthcare infrastructure and favorable government initiatives regarding population health management, North America held the highest revenue share in 2020. Asia Pacific is predicted to be the fastest-growing regional market from 2021 to 2028, owing to the developing healthcare infrastructure in countries such as Indonesia, China, and India.

Key players listed in this electronic health records (EHR) market include

Cerner Corp.
GE Healthcare
Allscripts Healthcare, LLC
McKesson Corp.
Epic Systems Corp.
NextGen Healthcare, Inc.
eClinicalWorks
Medical Information Technology, Inc.
HMS
CPSI
AdvancedMD, Inc.
DXC Technology Company
CureMD Healthcare
Greenway Health, LLC

New expansion activities, product approvals, product launches, partnerships, and acquisitions from these players have positively impacted the market in recent years. With the widespread adoption of digitized patient records, EHR-integrated medical transcription services are available, where physician narrations are entered directly into the EHR instead of into other word processing systems.

Related blogs:

Experts Highlight Pitfalls to Avoid to Succeed with Remote Patient Monitoring

08-July-2021 Julie Clements Medical Transcription

Remote Patient Monitoring

Remote patient monitoring (RPM), a subset of telehealth, allows healthcare providers to leverage technologies to deliver care to patients in their homes. In RPM, wired or wireless peripheral measurement devices such as glucometers, implantables, biosensors, blood pressure cuffs, and pulse oximetry to track and transmit patients’ healthcare data to their physician. RPM is used to monitor health conditions such as diabetes, health disease, blood pressure, weight gain/loss, dementia and substance abuse. Monitoring of vital signs alerts physicians of any problems and enable them to work with patients to manage their condition. Telehealth encounters are recorded using medical transcription services.

RPM offers many benefits for patients as well as healthcare organizations:

Improves care quality and clinical outcomes
Enhances efficiency and reduces costs
Decreases chances of readmission
Puts patients at ease – they can recover in the comfort of their homes, surrounded by their family
Provides patients more control over personal health
Boosts patient follow-through
Home health addresses geographical barriers
Can free up inpatient capacity during a public health emergency like the current pandemic by moving all patients home if they don’t have to be in the hospital

However, experts point out that to successfully implement RPM and leverage these benefits, providers need to focus on avoiding certain pitfalls.

Suboptimal Resource Allocation: Optimal resourcing is crucial to ensure alignment among all stakeholders – leaders, administrators and technicians as well as among the doctors, clinicians, nurses and caregivers who are actively involved in the program on a daily basis. In a Care Innovations report, an expert describes lack of focused resourcing as “the number one risk facing a remote patient monitoring implementation.”
Too many Interfaces: A recent HIT Consultant article reports RPM implementation will not work if patients have “too many disparate places that track their health”. Ensuring that all of the patient’s health information is centralized is crucial to make digital care more accessible and easier to understand. The ideal option would be set up a single app for the patient and integrate their RPM data on it. This will empower patients to actively participate in the managing chronic conditions and improve the overall digital health experience. Likewise, care teams should have all patient information consolidated on one dashboard.
Technology can also improve the overall telehealth experience. A secure online portal would serve as a single point of communication and allow patients to communicate with their healthcare provider including specialists, request prescription refills, schedule appointments, review test results and records of previous visits, and so on.
Not Educating Patients on how RPM Works: Enrolling the right patients in the program and making sure they understand how the program works and what to expect is essential to RPM success. Providers need to take time to educate and train patients on using the technology and make them comfortable with it. The program should include a touchpoint that patients can use to ask for clarification if they don’t understand something.
The Technology is Hard to Use: Patients won’t use the technology if it is difficult for them to track their health. Giving patients the option to sync their biometric devices with the health management platform will simplify data collection and also allow them to track their health easily. The app they are using must be able to display their RPM data clearly and logically. Patient engagement with digital health tools on a daily basis can be promoted in various ways such as creating medication reminders and making useful content available to help them manage their health. Presenting data visually as graphs or diagrams will help patients and providers recognize trends and take action.
Mobile-enabled RPM is a popular option for its ease of use by both patients and physicians. notifications to prompt patients to enter important data and once the data has been received, the physician can access and analyze the information to decide on whether the condition can be managed remotely or whether it calls for a face-to-face encounter.

The Centers for Medicare & Medicaid Services (CMS) has taken steps to improve reimbursement for RPM. According to a new survey by MSI International, patients are in favor of RPM, especially for monitoring of chronic diseases. About half want to see it integrated with clinical care services (mhealthintelligence.com), but expressed concerns about the accuracy of the technology and complications caused by the device used. Educating patients on monitoring their health using digital technology and ensuring the physicians can use patient data meaningfully is key to the success of RPM. Integration of the RPM platform with the EHR (electronic health record) allows providers to enter data directly into the medical record and access information needed for care management. With the rising demand for telehealth services and RPM, medical transcription outsourcing is a practical solution for healthcare providers to manage their EHR data entry tasks.