Write Good and Effective Progress Notes with These Key Tips [INFOGRAPHIC]

15-March-2021 Julie Clements Infographics

Progress notes or SOAP (Subjective, Objective, Assessment, Plan) notes, document various aspects of the patient’s treatment and highlight important issues or concerns relating to care. Good progress notes tell the patient’s story and prioritize patient care and safety. These notes provide information related to medical decision-making, patient-provider communication, critical thinking, billing and coding and medico-legal requirements for documentation. Medical transcription outsourcing is an ideal way to ensure EHR-integrated progress notes that are focused, concise, readable, organized, and useful.

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Progress Notes

Technology can Streamline Data Exchange for Successful Care Transitions

08-March-2021 Rajeev Rajagopal Medical Transcription Company

Technology

Having complete and accurate healthcare information is critical in all stages of the patient care process, and many hospitals and physician practices rely on medical transcription companies to ensure this. Care transitions involve many challenges and clear, accurate, relevant and up-to-date medical history should be readily available to clinicians when patients move from one setting to another.

“Transitions of care”, as defined by the Joint Commission, refer to the movement of patients between health care practitioners, settings, and home as their condition and care needs change. Accurate documentation of information is a key requirement for patient safety and quality of care during these patient handoffs. Providers can improve patient care transitions by ensuring up-to-date medical history and streamlining data exchange using technology, according to a recent article published by McKnight’s.

Causes of Ineffective Transitions of Care

Let’s first take a look at the root causes of poor-quality care transitions as listed by the Joint Commission and industry experts.

  • Communication Breakdowns: To ensure safe, continuous and coordinated care, there must be effective communication between clinicians and across multidisciplinary teams when patients are transferred from one setting to another. However, there is an increased risk of information being miscommunicated or lost during patient handovers. This can happen due to various reasons: differences in expectations between senders and receivers of the patients, lack of teamwork, absence of standardized procedures and not having enough time to successfully complete the hand-off.
  • Patient Education Breakdowns: Patients may not understand their medical condition and as a result, the importance of following their care plan. It can also happen that patients or caregivers don’t get clear instructions about follow-up care, or receive conflicting instructions, confusing medication regimens, and unclear instructions about follow-up care. Sometimes, patients and caregivers are left out from the planning of the transition process.
  • Accountability Breakdowns: When many specialists are involved in the patient’s care, no physician may take responsibility to ensure that the patient’s healthcare is co-ordinated across various setting and providers. This can create confusion for the patient and the clinicians responsible for the patient handover.
  • Poor Documentation: Poor documentation is one of the root causes of ineffective patient handoffs. Lack of proper documentation can lead to higher rates of readmission to hospital, failure to follow up after hospital discharge, increased costs related to poor care coordination, unavailability of critical diagnostic results, and medication errors.

According to the McKnight’s article, technology can help ensure that all patient care providers have up-to-date medical history and other relevant information quickly and easily to provide the best care during the patient’s care journey. The report provides three recommendations

  • Implementing a cloud infrastructure to enable providers to connect electronically with other care providers and exchange the right documentation quickly and securely.
  • Using health data exchange to improve communication and data transparency can help providers offer seamless, patient-centered care, regardless of the patient’s location.
  • Last but not least, educating staff and clinicians about the benefits of smooth communication and data exchange throughout the transition.

With the COVID-19 pandemic, urgent and rapid transitions in and out of care settings has become common. Ensuring that all care providers have the right information using technology can improve transitions.

“We have now entered into a new normal in senior care and providers simply need to share data in order to drive better health outcomes, says the author, Travis Palmquist, vice president and general manager of Senior Living at PointClickCare.

A report from Deakin University, Australia identified the minimum information elements to support seamless communication at transitions of care for patients with complex healthcare needs as:

  • patient details
  • family and caregiver support details
  • document author and location
  • document recipients and location
  • encounter details
  • problems and diagnosis
  • clinical synopsis
  • relevant pathology and diagnostic imaging investigations
  • clinical interventions
  • medications
  • allergies and adverse drug reactions
  • alerts
  • arranged services
  • recommendations for management
  • information provided to patient, caregiver and family
  • nominated primary health providers

Outsourced medical transcription services can play an important role in ensuring that these details are readily available in all settings and every stage of care. A reliable medical transcription company can provide accurate and timely documentation of history and physical reports, discharge summaries, operative notes or reports, and consultation reports and more, which are critical for workplace efficiencies, and to improve care outcomes and ensure seamless engagement across clinicians and healthcare staff treating the patient.

How to Maintain Accurate and Complete Chart Notes in Dentistry

04-March-2021 MTS TEAM Medical Transcription Outsourcing

Dentistry

As every medical transcription company knows, accurate and timely clinical documentation is critical for all medical specialities. Dentistry is a separate area of medicine and producing and maintaining clear, accurate and accessible patient records are a vital element of the dentist’s professional responsibility.

Importance of Keeping Good Dental Records

Accurate and complete clinical dental records are important for many reasons:

  • Allow for effective communication between health care providers
  • Support rationale for treatment
  • To optimize the safety and effectiveness of patient care
  • For quality-of-care assessment and follow-up
  • For forensic purposes
  • To aid teaching and provide a database for dental research
  • To provide evidence in a court of law, such as in the defense of malpractice claims

What are Complete Dental Records?

A complete dental record should include the following items:

  • Medical and dental history – medical conditions requiring premedication, history of infectious disease or illness, allergies and any tobacco, drug or alcohol usage. The patient should be asked about any specific areas of concern
  • Examination findings
  • Diagnoses and risk assessments
  • Treatment and prevention plans – treatment information should include current dental complaint, current oral condition by examination and radiograph findings; a complete description of the dental treatment to be performed should be documented
  • Procedure performed, and pre- or post-op instructions given to the patient
  • Whether or not any complications occurred
  • Medications – type and amount of medication, including name, strength, number of tablets, dosage level and time interval and the number of refills if any
  • Anesthetics were used, pre-medication and post-medication
  • Treatment notes
  • Patient communications including informed consent / dissent
  • All discussions about the procedure, payment, and billing
  • Pharmacy communications
  • Provider identification
  • Patient information
  • Radiographs, photographs, and study models
  • Dental laboratory communications and lab results
  • Communications with specialists and physicians
  • Waivers and authorizations

Dental SOAP Notes – A Good Way to Document Each Patient Visit

SOAP is highly recommended as a good method to document visits in a dental practice. SOAP stands for Subjective (complaints & history), Objective (testing & exam findings), Assessment (diagnosis) and Plan (treatment plan).

  • Subjective: The patient’s chief complaint, reported symptoms, and health issues that may affect the outcome of treatment as documented in the history
  • Objective: Findings of the examination, including vitals, mental state, history of illness and health issues related to diabetes, heart, implants, weight, smoking, pregnancy, any evidence of symptoms affecting the teeth, tissue and bone such as evidence of periodontal disease, endodontic infection, and fracture, decay, missing teeth and broken restorations and prosthetics
  • Assessment: Listed in order of priority, what the doctor sees as necessary for the patient to return to health, based on information gathered in the subjective and objective sections.
  • Plan: The actual treatment plan and the treatment performed, and what will be done to address each complaint, including materials, anesthesia, tooth number, medications and any referrals to other specialists or providers.

Each patient’s SOAP note is unique in terms of the information it contains and the length of notes. Good dental SOAP notes and reports greatly improve communication among dentists, physicians and insurance carriers. This method can help providers avoid charting mistakes or omissions.

Electronic health record (EHR) systems enhance both the quality and quantity of information available to healthcare providers for decision making, and are designed to improve care quality and patient safety. An EHR system has the ability to capture detailed clinical information in a highly structured manner. However, EHRs come with various usability challenges such as confusing information display, difficult data entry that can lead clinicians to use workaround solutions such as copy and paste, and problems in system feedback and workflow support (www.pewtrusts.org). EHR can auto-fill the notes and this can be especially problematic. Automated insertion of previous or outdated information using EHR tools, if not modified to be patient-specific and relevant to the visit, can affect quality of care and compliance and lead to medical liability issues.

Tija Hunter, CDA, EFDA cautions: “Many of us now use “auto notes,” a wonderful feature in our practice management software that allows us to “cheat” and create great notes at the click of the mouse. However, if you don’t have the auto note feature set up correctly, then you won’t get good content. Garbage in means garbage out! (Dentistry IQ).

All of these aspects should be taken into account when creating chart records in dental practices. Accurate chart notes tell providers exactly what was done during the course of a day.

Outsourcing medical transcription is a smart way to maintain the integrity of chart notes in dentistry. This is a practical option even in practices that use voice recognition for EHR documentation. Medical transcription services are a valuable validation step to prevent data quality problems and documentation errors.

Dos and Don’ts for Telemedicine

01-March-2021 Julie Clements Medical Transcription

Telemedicine

Virtual healthcare has become widely accepted as a way for physicians to remain connected with patients during the global coronavirus pandemic. Real-time, audio-video communication between physicians and patients had been in force prior to the pandemic. Now, telemedicine ensures that people with chronic and other serious conditions get the care they need as they follow stay-at home-orders. HIPAA compliant medical transcription services ensure that these encounters are securely documented.

The global telehealth market size is projected to expand at a compound annual growth rate of 23.4 per cent and reach US$266.8 billion by 2026, according to a report from Fortune Business Insights. Whether telehealth is provided by video visits or phone calls, medical practices need to know the dos and don’ts of implementing a remote care strategy.

Dos

  • Develop guidance for providers to deliver virtual care to patients in any location in accordance with state and federal guidelines.
  • Practitioners should check whether existing law allows them to provide telehealth services and, if so, whether additional legal requirements or restrictions apply. They would also need to confirm with insurance companies that they can bill for reimbursement. They should know the codes that can be billed and the services that cannot be billed via telehealth and also check malpractice insurance.
  • Choose technology that is most effective and accessible for the patient. Train physicians and clinicians about how to use the telehealth technology. Providers should be trained on how to navigate the virtual portal, access workpools, and also interact with patients over the video or telephone. IT staff should test connectivity and remain available for problem solving.
  • Prepare for the visit. Send the patient instructions in advance of the visit. Obtain patient consent and past medical, surgical, and social history.
  • Make sure that the patient’s settings are favorable to a smooth virtual encounter – ask the patient to lower background lighting, reduce background noise, charge device battery, and if possible, evaluate bandwidth.
  • Use a secure room for telehealth visits and inform patients about the steps taken to secure your room, including the security of the technology used and any other precautions taken to safeguard patient information.
  • r first session. Ensure good lighting. Overhead lighting is best as it can distribute light evenly. Camera placement should be such as you can maintain good eye contact with the patient during the entire visit. Choose the right set up for your monitor, especially if you want to take notes during the session. Have a computer charger handy so that potential power failures won’t disrupt the session. Ask your patients to do the same as well.
  • Create the necessary documentation templates to track activity within the electronic health record (EHR) for eVisits and phone encounters. Maintain the structure of the in-person clinical note template. Partner with a reliable medical transcription service vendor to document virtual visits.
    At each encounter, document the following:

    • Key points observed by the attending clinician
    • Plan of care requiring medical decision making
    • Total time spent with the patient
    • Any exam components not completed because of telehealth limitations
  • Use medical devices for remote monitoring of in-home care and improve clinical observations. These devices, which include wearable sensors, implanted equipment, and handheld instruments, enable valuable patient data to be collected and sent to monitoring centers to track patients’ vital parameters and clinical status real-time.
  • Offer convenient payment options and address any payment barriers for telehealth services so patients can quickly access care. Offering digital payments and mobile payments can improve the patient experience and also practice cash flow.

Don’ts

  • Don’t forget to focus on the patient experience – invest time to make patients comfortable using the technology, whether it is video conferencing, using new tools or downloading specific apps to support their care. This is especially important for elderly patients.
  • Don’t use a virtual background. Stick to neutral or color video backdrops for a telemedicine visit.
  • Don’t use a cell phone as far as possible and don’t do your visit when you are in a car or taking other calls.
  • Don’t assume telehealth HIPAA flexibilities provided by the Office of Civil Rights in the wake of the pandemic will last forever. Use technology that is HIPAA compliant and choose HIPAA-compliant medical transcription services to document virtual visits.
  • Don’t forget to confirm patient identity before the visit. Also, always introduce yourself and your staff to the patient.
  • Don’t conduct telehealth visits in public or group settings where others can overhear patient information.

According to a McKinsey & Co. report, physicians saw between 50 and 175 times more patients via telehealth than they did prior to the pandemic. Going by these dos and don’t can improve the quality of virtual online consultations. Outsourcing medical transcription can ensure quality documentation of telehealth encounters.

Cloud-based EHR Systems for Medical Practices – Key Advantages

25-February-2021 Rajeev Rajagopal Medical Transcription Outsourcing

Cloud-based EHR systems

Electronic health record (EHR) systems can be either cloud-based or on-premise based. It has been reported that efficient transition to cloud computing could protect patient data. Medical transcription outsourcing allows physicians and their staff to focus on patient care and save time spent managing burdensome EHR documentation tasks. Practices can enjoy diverse benefits by using cloud-based EHR interoperability solutions.

10 Advantages of Cloud-based EHR Systems in Medical Practices

Cloud based ehr

Interoperability also supports telehealth medicine, which gained immense significance during the COVID-19 healthcare crisis. Investing in reliable and accurate medical transcription services along with a cloud-based EHR helps physicians share medical records easily as well as improve communication and compliance. Cloud-based EHR can create a more patient-centered healthcare system and protect patient data from any breaches.

5 Key Considerations when Expanding Telehealth beyond the Pandemic

22-February-2021 MTS TEAM Medical Transcription Company

Telehealth

Telemedicine – the delivery of healthcare using digital communication technology – has been around for a long time, but has faced numerous obstacles to widespread adoption. Beyond some operational and clinical hurdles, the extensive implementation of telehealth has been hindered by various legal and regulatory barriers. With the COVID-19 pandemic and the social distancing – that is recommended as the standard for mitigating its impact- the adoption of telehealth increased rapidly across the country. Federal and state laws and regulations that were once a hurdle were relaxed to enhance the ability of physicians to provide and patients to receive telehealth services effectively. Many industry experts see this as a real opportunity for medicine to embrace telemedicine and remote monitoring more often. They are also predicting that telehealth will continue to stay and grow even after the pandemic, and our medical transcription company agrees with these views.

telehealth virtual

Find out how our medical transcription service can support your practice’s transition to telehealth and enhance patient care.

Call us at 1-800-670-2809.

Telehealth’s Impact on Healthcare and Accessibility beyond the Pandemic

As telehealth has the potential to reduce healthcare costs, change the way providers treat their patients, and improve patient outreach and health outcomes, many professional medical societies endorse telehealth services and provide guidance for medical practices in this evolving landscape (cdc.gov). Moreover, in a post-pandemic world, we can expect that telehealth technology will advance further, which will accelerate its influence on the healthcare industry.

Telemedicine also helps patients who need continuing treatment, live in remote locations, or have limited mobility. These are just a few of the other advantages it offers beyond crisis response. The seamless integration of telehealth services into current infrastructure is crucial to enhance patient care and broaden healthcare accessibility as healthcare systems undergo continuous adaptation.

Want to know how EHR documentation is done for Telehealth visits? Read our blog post Strategies to Streamline EHR Documentation for Telehealth Visits

Top Tips for Effective Documentation in Occupational Therapy

18-February-2021 Julie Clements Occupational Medicine Transcription

Occupational Therapy

Like any other medical specialty, occupational therapy (OT) has distinct documentation requirements. Today, electronic health records (EHR) supported by medical transcription services have eased patient data management challenges for occupational therapy practitioners. Experts say that to get the most of EHR systems, occupational therapists should individualize patient reporting.

Goals of Documentation in Occupational Therapy

According to American Occupational Therapy Association [AOTA] guidelines, the purpose of documentation in OT is:

  • Communicate information about the client from the occupational therapy perspective;
  • Articulate the rationale for provision of occupational therapy services and the relationship of those services to client outcomes, reflecting the occupational therapy practitioner’s clinical reasoning and professional judgment;
  • Create a chronological record of client status, occupational therapy services provided to the client, client response to occupational therapy intervention, and client outcomes, and
  • Provide an accurate justification for skilled occupational therapy service necessity and reimbursement

Common Types of Occupational Therapy Reports

Providers must ensure proper documentation of professional occupational therapy services. Proper EHR documentation can streamline office workflow, improve document management speed and efficiency, reduce health records errors, and importantly, enhance patient care. Effective documentation is also critical for appropriate reimbursement. Medical transcription companies specialized in occupational therapy transcription help providers document many types of reports. The most common are:

  • Screening Reports: This report is aimed at identify and documenting the patient’s needs and possible rehab potential to determine if skilled OT services would benefit them. Level of function at admission, current pain scales, functional level charting, and other related aspects would be covered in the chart review.
  • Evaluation and Reevaluation Reports: The evaluation report would include an analysis of occupational performance and list of factors that support and hamper performance and participation. It would also identify the specific areas of occupational performance to be addressed, interventions, and expected outcomes. Providers can also document types of assessments used and results. The reevaluation report contains the results of the reevaluation process.
  • Intervention Reports: Interventions provided are based on results of evaluation or reevaluation processes. The report documents the goals, intervention approaches, and types of interventions to be used to achieve the patient’s identified targeted outcomes. The progress note and transition plan are part of the intervention report.
  • Outcomes: This comprises the discharge report which summarizes the occupational therapy services provided and outcomes. It would also include recommendations relating to the patient’s future needs, and follow-up plans, and referrals to other providers, if applicable.

Best Practices for Effective OT Documentation

But how can occupational therapists ensure effective EHR documentation? We have put together top tips from industry experts for efficiency in occupational therapy documentation:

  • See that each Patient’s Note is Individualized: The success of documentation depends on the ability of the occupational therapist to individualize patient reporting, according to Cathy Brennan, MA, OTR/L, FAOTA. Speaking to AOTA, she strongly advises against cut and paste documentation which looks similar for each patient. The copy and paste function in EHRs is intended to allow medical practitioners to reuse information in patient EHRs easily and efficiently, without having to re-enter the data. However, this can lead to serious errors. When copying and pasting information between different patients’ EHRs, providers can end up compromising patient safety, especially if the information relates to allergies, discharge summaries, medications, surgical notes, and vital signs. Brennan recommends that practitioners demand EHR options that will allow them to document each individual’s responses and functional outcomes.

    Individualized notes mean, “making every goal and treatment session client-centered. Include client comments and goals. This will further justify different interventions and activities utilized in the therapy session” says Occupational Therapist/Hand Therapist. Emillee Johnson OTR/L, CHT (www.aota.org).
  • Begin the Patient’s Story using the Subjective Part of the Note: This is important to justify the patient’s need for occupational therapy services. OT Potential advises therapists to begin the note using feedback from the patient about their therapy sessions and home exercise program – what is working for them and what is not.
  • Document Observations and Interventions in Detail: objective section of your evaluation and/or SOAP note should contain objective measurements, observations, and test results. OT assessments, manual muscle tests (MMTs), range of motion measurements, level of independence, functional reporting measures, wound healing details (for post-op patients), objective measures from assessments related to the diagnosis.
  • Avoid Documenting Unimportant Information: Best practice is to document only what contributes to the patient’s story, including medical necessity and anything that improves the patient’s functional abilities/outcomes. Documenting irrelevant matters can be a waste of time. As Brennan advises, “write better, not more”.
  • Document Observations: In addition to the interventions provided, practitioners should also document their observations to validate skilled care and clinical reasoning. Documenting the patient’s response to each intervention, instructions to ensure understanding or proper technique, and how the interventions were useful to meet the patient’s functional goal.

Finally, ensure timely documentation. Patient records must be documented in a timely manner to ensure accurate reporting of events. Real-time or point-of-service documentation is one option, but this can take away focus from the patient. Good eye contact with the patient is extremely important in the occupational therapy consult. Another more practical option is to document soon after the visit using occupational therapy transcription services.

Telemedicine Visits – What are the Best Practices?

15-February-2021 Rajeev Rajagopal Medical Transcription Outsourcing

Telemedicine

Telemedicine has proven to be an effective treatment option, mainly during the care challenges created by the COVID-19 pandemic. This healthcare advancement reduces disparities in access to care, allows patients to get care at home and save costs. Medical transcription outsourcing companies can help physicians document these virtual encounters. By maintaining social distancing, physicians can engage with patients without in-person consults, avoid physical contact with symptomatic individuals, reduce chances of spread by preventing exposure in waiting rooms, and keep high-risk people at home.

virtual consultation

Experts opine that remote health may continue to be the trend for chronic care management, health and wellness, and other ancillary services even after the current public health emergency. Telemedicine providers can consider outsourcing medical transcription tasks to an experienced company for accurate and timely documentation of patient notes.

Medical Transcription Services Market to Reach USD 8176.8 Million by 2026

11-February-2021 MTS TEAM Medical Transcription Company

Medical Transcription Services Market

Converting voice-recorded medical reports into accurate transcripts is important for physicians or other healthcare professionals for future reference, easy access to report and faster sharing to other providers when required. Physicians often rely on professional medical transcription companies to get the task done accurately. Medical reports that need to be transcribed can be voice files, notes taken during a lecture, or other spoken material, and are often dictated over the phone or uploaded digitally via the internet or through smartphone apps.

According to a report from 360 Market Updates, the global Medical Transcription Services market size that was USD 5597.7 million in 2019, is expected to reach USD 8176.8 million by the end of 2026. This market is predicted to grow at a CAGR of 5.5% during 2021-2026.

In 2021, the market will be growing at a mild rate and with the rising adoption of strategies by key players, the market is predicted to rise over the projected horizon.

Key factors that drive the growth of this global team include

  • adoption of medical documentation and recording systems
  • government initiatives in health information infrastructure
  • implementation of EHRs
  • technological innovations through the use of electronic technology to reduce turnaround time and
  • increasing focus on lowering costs, increasing productivity and improving the quality of patient care while ensuring patient’s safety

Medical transcription services market is segmented by Type, and by Application.

By Type, the market is divided into Outsourcing and Offshoring. By Application, the market is segmented into Hospitals, Clinical Laboratories, Academic Medical Centers, and Others.

The key regions covered in the report are North America, Europe, China, Japan, Southeast Asia, India and Central and South America. North America currently dominates and is expected to retain its position in the medical transcription services market in the future, owing to factors such as rise in aging population and passing of Patient Protection and Affordable Healthcare Act, 2013.

The major vendors discussed in the report include Mmodal, Nuance Communications, Transcend Services, Acusis, iMedX Information Services, MTBC, nThrive, Medi-Script Plus, Outsource2india, TransPerfect, VIVA Transcription, Medscribe, Pacific Solutions, Same Day transcriptions, DoctorDocs, World Wide Dictation, Athreon, BVS Transtech, Excel Transcriptions, GMT, and LC Transcription Services.

Even with the availability of diverse software to perform transcription, EHR-integrated medical transcription services performed by skilled transcriptionists are a preferred choice of many physicians because of the 99% accuracy ensured.

Telehealth Proving to be a Viable Option for Follow-Up Care

08-February-2021 Julie Clements Medical Transcription Company

Telehealth

Telehealth adoption reached a new high during the Covid-19 pandemic. In February 2020, the Centers for Disease Control and Prevention (CDC) issued guidance recommending that health care providers in areas affected by the COVID-19 pandemic adopt social distancing practices and offer virtual care through telehealth. Medical transcription companies have risen to the challenge and successfully helped providers manage their EHR documentation. The Centers for Medicare and Medicaid Services (CMS) supported telehealth in a big way by waiving various restrictions in response to the public health emergency. According to a study published by the CDC, approximately 1,629,000 telehealth encounters occurred in the first 3 months of 2020 (early pandemic period), compared with about 1,084,000 encounters during the same period in 2019 – a 50% increase overall.

Telehealth is a useful tool to treat various medical conditions. According to telemedicine company Chiron, virtual care is an ideal option for follow-ups in the following areas:

  • Management of chronic conditions
  • Medication adjustments
  • Reviewing abnormal labs or imaging
  • Minor urgent care
  • Postop follow-up

Follow-up is an essential element of patient care. There are two main benefits to conducting follow-up care: first, follow-up keeps patients healthier and promotes positive outcomes. Second, regular post-discharge check-ins drives better compliance and can help reduce hospital readmissions. Without effective follow-up, conditions like diabetes and heart disease can have a significant impact on patients’ health and lifestyle.

Recent reports point to the viability of virtual care for follow-up care. A study published in the American Journal of Managed Care reported that 79 percent of the patients said that finding a convenient time for a follow-up telemedicine visit was easier than for a conventional office visit. Up to 52.5 percent of clinicians also reported that telemedicine visit was more efficient compared to the traditional office visit.

  • Recovery after Surgery: Studies have reported that using telemedicine for follow-up can improve patient outcomes for surgery recovery. Follow-up provided via virtual platforms offers many benefits for convalescent patients, those who have mobility challenges and people who have a busy lifestyle.
  • Diabetes: Diabetes self-management is closely tied to lifestyle modifications. Monitoring and follow-up for this common chronic disease can be effectively accomplished through telehealth. A randomized controlled trial that evaluated the use of telehealth for managing patients with type 2 diabetes found that patients who were monitored virtually had better outcomes than those in the control group (www.healthrecoverysolutions.com). The telehealth system allowed the nurse case manager to track the patients virtually in real time and alter medication dosage as needed, under a physician’s supervision. At 6 months follow up, it was found that patients in the telehealth intervention group had:
    • Notably lower HbA1c levels than the usual care group
    • A significantly faster rate of decline in HbA1c levels compared to the usual care group
    • Better adherence to therapy
    • Improved patient-provider communication

    Importantly, the study found that follow-up care via telehealth improved patient adherence in many ways. Patients could easily report their daily blood glucose levels using the telehealth platform. The healthcare provider could quickly evaluate the patient’s status and titrate medications when necessary. Telehealth also promoted regular communication between the patients and the provider.

  • Orthopedic Care: A study published in the Journal of Clinical Orthopaedics and Trauma in October 2020 found that telemedicine emerged as an effective follow-up option for providing patients with important information about orthopedic self-care and medications – without a hospital visit. Among the patients using telemedicine, 71.43% could be managed without needing physical visits to the outpatient-department and patient satisfaction rate was 92% among those who availed telemedicine. Physical outpatient visits were recommended only when physical exam was needed or patient-physician communication failed. The researchers concluded that virtual care can effectively reduce the need for physical visits to outpatient-departments for follow up of orthopedic patients.

Providing timely follow-up care is very important. Medical transcription services ensure documentation of the physician’s narrative in the EHR. With complete medical records and EHR integrated telehealth, healthcare providers can provide quality patient care, including follow-up.

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