Check Out Our Top 10 Blog Posts of the Year 2020

31-December-2020 MTS TEAM Medical Transcription

Medical Transcription Software Market to Reach USD 4.89 Billion by 2027

28-December-2020 Julie Clements Medical Transcription

Medical Transcription Software

Accurate transcripts of patient reports are necessary for physicians to take appropriate treatment decisions as well as for future reference. Along with the services provided by professional medical transcription companies, many practices are also using transcription software to dramatically reduce the clinical documentation time and thus enable physicians to focus more on patient care.

According to a report from Fortune Business Insights, the global medical transcription software market size that was valued at USD 1.32 billion in 2019, is expected to reach USD 4.89 billion by 2027. The market is predicted to exhibit a CAGR of 17.8% during the forecast period 2020-2027.
The report highlights that even amid the COVID-19 pandemic, this global market has registered a positive impact, while the healthcare industry has registered decline in certain markets. One of the important industry trends is the demand for digital documentation across several healthcare spheres as they contribute to the ease of management and treatment of chronic and serious diseases.

Key factors that boost the market growth are –

Transition from traditional transcription services to AI-powered solutions that provides diverse advantages – faster transcription and greater accuracy
Growing importance of clinical documentation in healthcare for the provision of quality patient care, which is expected to boost the adoption of EHR/EMR
Government regulations and acts that are projected to boost the adoption of clinical documentation systems
Technological advancements such as voice recognition, artificial intelligence, and machine learning in transcription software
Faster transcription compared to keyboard typing lowers the cost of overall documentation

Certain factors that restrain the market are – low software adoption, risk of cyber security breaches, cyber-attacks that hamper market growth, the lack of healthcare IT infrastructure in emerging markets and issues related to software adoption such as workforce training.

The report divides the market on the basis of deployment, end user facility, type, end user and geography.

Based on deployment, the market is segmented into cloud/web based and installed/on-premises. Of these, the cloud/ web-based segment is projected to grow at the highest CAGR during the forecast period, owing to factors such as the deployment of cloud-/web-based software, upcoming launches of advanced cloud-based software, increasing adoption of electronic health records, benefits of cost-effectiveness, ease of use in massive workload, smoother transactions and the expansion of healthcare IT infrastructure. At the same time, installed/on-premises segment is anticipated to lose its market share due to the higher maintenance costs associated with it.

On the basis of the end user facility, the global market is divided into hospitals, diagnostic centers, clinics, and others. Here, the hospitals segment is expected to grow at the strongest CAGR, due to the rising demand for advanced healthcare facilities and an increased emphasis on clinical documentation across the globe. Clinics segment are also projected to register strong growth, owing to increasing adoption of EHR/EMRs in clinics. Diagnostic centers segment is expected to drive the growth, owing to increased adoption of voice recognition technology for medical transcription.

Based on type, the market includes voice capture and voice recognition. The voice recognition segment is expected to account for the highest revenue during the forecast period, as this allows physicians to lower the documentation time and enjoy other benefits such as improved accuracy, reduced cost, and improved flexibility.

End users of this global market are radiologists, clinicians, surgeons, and others. The clinicians’ segment is to register the highest CAGR due to the higher number of patient encounters and the implementation of government regulations for the consolidation of clinical documentation. Owing to the increasing number of medical imaging procedures across the globe, radiologists are expected to account for a considerable CAGR in this market. However, surgeons are predicted to have lesser market shares owing to comparatively lesser patient encounters and thus reduced need for medical transcription.

Geographically, the market is divided into North America, Europe, Asia Pacific, and the Rest of the World. Europe is expected to register strong growth during the forecast period due to the increasing adoption of cloud and voice recognition technologies in healthcare and a higher emphasis on the utilization of advanced technologies in order to streamline clinical workflow and documentation in major countries like the UK, Germany and France.

Due to rising awareness about clinical documentation, and greater need for better treatment outcomes for patients, the Asia Pacific region is projected to register the highest CAGR. The Rest of the World segment is expected to register better growth due to improvement in healthcare infrastructure in regions such as Latin America, and Middle East & Africa.

Key market players profiled in the report include

Nuance Communications, Inc. (Burlington, U.S.)
MModal IP LLC (3M) (Franklin, U.S.)
Dolbey @ (Cincinnati, Georgia)
Acusis LLC (Pittsburgh, U.S.)
Voicebrook, Inc. (Lake Success, U.S.)
Speech Processing Solutions GMbH (Philips Dictation) (Vienna, Austria)
Xelex Digital LLC (WebChartMD) (Johnson City, U.S.)
nThrive, Inc. (Alpharetta, U.S.)
Scribe Technology Solutions (Naples, U.S.)
ZyDoc Medical Transcription (Islandia, U.S.)
Other Players

Owing to its unique technology, strong and varied range of product offerings, robust distribution network, sophisticated quality, and post-sales support, Nuance Communications is considered to be the leading player in the market. Philips Dictation (Speech Processing Solutions) is considered to be the second leading player in the global market. Factors such as considerable market hold in emerging nations, strong supply chain network, and focus on collaborations with healthcare institutions is expected to maintain its position in this market.

Practices adopting medical transcription software can use the services of experienced transcriptionists to proofread the transcripts and ensure accuracy.

6 Common Causes Of Medical Errors [INFOGRAPHIC]

24-December-2020 Rajeev Rajagopal Infographics

Accurate medical records reflect physician efficiency and are indicative of quality patient care. Maintaining accurate medical records is also essential to meet ethical and legal obligations. Error-free medical records with all relevant patient data allow physicians to monitor the treatment given to the patient and reduce risk. Healthcare organizations hire medical transcription services to help physicians maintain accurate EHR documentation.

Check out the infographic below

Medical Errors

Guidelines and Tips to Write Good Progress Notes

21-December-2020 MTS TEAM Medical Transcription Outsourcing

Progress Notes

Progress notes are among the most important reports that a medical transcription company helps physicians document in the electronic health record (EHR). These brief notes, also called SOAP (Subjective, Objective, Assessment, Plan) notes, document various aspects of the patient’s treatment and highlight important issues or concerns relating to care.

Clinicians need to know how to ensure effective and efficient EHR documentation. Good progress notes tell the patient’s story and prioritize patient care and safety. According to a new study published in the Association of American Medical Colleges’ MedEdPortal, sufficient EHR documentation training can enhance a resident’s knowledge of writing progress notes, which in turn, could lessen the risk of clinician burnout in the future. Researchers at the University of Wisconsin School of Medicine and Public Health (UWSMPH) found that EHR training workshops helped residents grasp the details and intricacies of EHR documentation (www.ehrintelligence.com).

Aims and Functions of Progress Notes

Progress notes provide information relating to the following:

Medical decision-making: Progress notes allow clinicians to record their work with the patient. This includes the clinician’s ongoing efforts to assess and manage the patient’s symptoms.
Patient-provider communication: A progress note covers the entire interaction between the patient and health professionals, including physicians, nurses, pharmacists, dietitians, and physiotherapists
Critical thinking: Patient notes reflect the knowledge, skills and attitudes attributed to critical thinking and clinical reasoning. They demonstrate the clinician’s reasoning and judgment when dealing with complex and challenging treatment situations, and the problem-solving process.
Billing and coding: Clinical documentation drives coding and billing. Accurate and compliant progress notes is critical for correct assignment of codes, which in turn, paves the way for maximum reimbursement, lower denial rates, and compliance.
Medico-legal requirements for documentation: Thorough and thoughtful documentation can provide a strong defence in the event of a medical negligence investigation.

What progress notes should include

Good and effective progress notes are accurate, complete, factual, organized, timely, compliant with health laws and meet facility standards. Information that may be included in a progress note:

All treatment provided to the patient in chronological order, along with length of session
Precise assessments of the patient’s response to the treatment (progress and/or lack of progress), and needs
Significant events, emergencies and action taken
Clinical impressions regarding diagnosis, and or symptoms
Treatment plan
Modification(s) of the treatment plan
Medications used by the patient
Rationale for orders written including medications and treatments
Treatment compliance/lack of compliance
Collaboration with other professionals
Referrals made/reasons for making referrals
Safety issues
Recommendations for revisions in the treatment plan

Progress notes entries in the EHR must include the author’s name, the date, and the time and be authenticated and attested with an e-signature.

Writing Effective Progress Notes

The UWSMPH study found that while residents understood the purpose and the key components of progress notes, they were unsure how to construct the notes and why specific details, such as past medical history, lab results, and vital signs, were included in the notes. Here are guidelines and tips to write effective progress notes:

Tell the patient’s story: Patients come to the clinician with a problem and when asked about it, will explain their experience during the history and physical exam. The clinician has to listen carefully to the patient’s story. The health professional then has to document a story that makes logical sense, recommends Osmosis. The patient’s story should form the clinician’s assessment.
Refer to specific components in the treatment plan: When writing weekly and monthly progress notes, specific components in the treatment plan must be referenced (www.dphhs.mt.gov). This will help establish the link between the progress note entry and the patient’s treatment plan and the outcome of treatment and any observation that could justify altering the patient’s course of treatment. A practical approach would be to summarize information about a series of treatment services into a single progress note.
Record all details of unusual events: When documenting an unusual or noteworthy event in the progress notes, information recorded should include:
- a description of the incident with date and time of occurrence
- assessment of whether the event is significantly different from the patient’s typical behavior
- the reason for the event’s occurrence
- how staff responded
- recommendations for future interventions to be used
- modifications to the treatment plan, medication, or the patient’s environment)
Ensure that assessment is documented correctly: Diagnosis documented will stick, notes Osmosis, and that’s why it’s essential for the clinician to ensure that the assessment is recorded correctly. If the provider is unsure about something, even that must be added in the assessment. The American Academy of Family Physicians (AAFP) instructs that the physician should “never assign a diagnosis unless that diagnosis has been confirmed by diagnostic testing, or is otherwise certain”. AAFP identifies uncertain diagnoses as including those that are: Probable, Suspected, Questionable, “Rule out”, Differential, and Working. If a definitive diagnosis cannot be established, the signs, symptoms, abnormal test result(s), or other conditions that prompted the patient encounter should be documented.
Write out a specific plan: The progress note should include the treatment plan, tests, and therapies. The rationale for ordering something or initiating a treatment should be explained. There should be sufficient specific details in the plan. For e.g., instead of writing ‘antibiotics’, the provider should list the name of the antibiotic and when it will be started, and explain the indication, duration, and reason for antibiotic choice as well as how response to treatment will be monitored.

To sum up, the clinician’s focus should be on developing and implementing a quality treatment plan and writing effective and useful progress notes. It’s essential to avoid abbreviations, and strictly avoid cutting and pasting from previous notes without editing and updating. Indiscriminate use of the EHR copy-paste function can lead to inconsistent progress notes and unnecessarily long progress notes. Healthcare organizations should have clear policies and procedures in place to ensure proper EHR documentation and provide education and training for clinicians to promote good progress notes. Medical transcription outsourcing is a practical way to ensure that EHR-integrated progress notes that are focused, concise, readable, organized, and useful.

How to Travel Safely without Fears of Covid-19 Dampening the Mood

17-December-2020 Julie Clements Medical Transcription

Travel

With the times we are in, the rising number of coronavirus, or Covid-19 cases have filled the festive season with gloom. As an experienced medical transcription company, MOS deals with an increasing number of case reports detailing similar symptoms.

The Progress of Covid-19

The Covid-19 pandemic keeps manifesting itself through successive waves, making any semblance of normalcy only temporary. The initial total lockdown restrictions in the United States were modified to accommodate more relaxations, particularly in dining outside. That only helped usher in the next wave of Covid-19, making going out quite risky. But how long can you restrict yourself to your home and keep the task of heading outdoors reserved just for essential chores?

Surely You Can Travel Safely

With the festive season right here, your family would need a vacation or an outdoors relaxation of some sort to unwind from the stress of the whole year. Is it possible to have fun outdoors with the pandemic around? Let’s look at some realistic options of traveling in this festive season despite the pandemic. Don’t take our word for it, these opinions come from doctors.

General Travel Precautions

Dr. Kirsten Bibbins-Domingo of UC San Francisco’s Department of Epidemiology and Biostatistics believes the best option is to avoid traveling, keeping in mind the surge in infections. But if you should travel, research the destination to find out if it’s a coronavirus hotspot. There could be local restrictions you need to consider and those communities would be required to follow certain isolation directives. You would perhaps need to quarantine yourself if you visit a new state or community. So, make sure you don’t visit such destinations where Covid-19 cases are high and the resultant precautions and restrictions are severe.

There are precautions you need to take while you travel. Bibbins-Domingo reveals that surfaces don’t play as much a role in transmitting the virus as once thought, according to studies. But make sure the hotel you stay in follows sanitation protocols and uses the kind of cleaners that specifically kill SARS-Cov-2, the virus causing Covid-19. These precautions also apply to rental car companies you hire.

Air Travel Precautions

You also need to take precautions while traveling by air. Firstly, don’t be too keen on booking an airline selling middle seats. It’s easier for the infection to spread if you’re sitting between two individuals. Secondly, make sure the airline has the practice of enforcing mask wearing.

Dr. George Rutherford, UCSF’s Prevention and Public Health Group director, recommends avoiding bus travel. While traveling in your car, make sure all the occupants have face masks on and the windows are all open. In air travel, Rutherford recommends choosing a window seat somewhere in the middle between the restrooms at the front and the rear of the plane. This reduces the chances of people getting past you to get to the restrooms.

With some care, you can minimize the chances of the virus infecting you. Make sure you, and the people traveling with you, are fully aware of the risks involved and the danger you could unwittingly welcome if restrictions aren’t followed.

As one of the reputable medical transcription companies in the US, MOS provides advanced HIPAA medical transcription. We certainly would like to see reduced cases and the eventual end of this pandemic. Small steps can go a long way in containing the virus, till the vaccine sees wide circulation.

Hybrid Model Shaping the Future of Healthcare, say Reports

10-December-2020 MTS TEAM Medical Transcription

Healthcare

Healthcare will undoubtedly be a key consideration in every aspect of life in 2021. Telehealth adoption and acceptance surged during the pandemic, and US based medical transcription companies helped providers tackle their EHR data entry tasks. As the COVID-19 crisis developed, the Centers for Medicare and Medicaid Services (CMS) reported over an 11,000% increase in video- or phone-based visits. In May, healthcare facilities opened their doors for regular business and the following weeks saw a drop in virtual visits. While telemedicine provider Amwell reports that tech-based healthcare is here to stay, the future of healthcare is expected to be a hybrid approach as some procedures like immunizations, blood work, and imaging will always need an in-person visit.

The findings of the Amwell survey as summarized by www.benefitspro.com show why a hybrid model may be shaping the future of healthcare:

Up to 70% of the 600 providers surveyed reported they expect to continue using telehealth “sometimes or frequently” in three years.
Telehealth use is not just restricted to urgent care, with more providers and consumers using it for primary, chronic and specialty care.
21% of providers use three or more telehealth platforms and usability is a key criterion for both patients and doctors.
Many consumers are not familiar with accessing virtual care, and less than two-thirds of people in rural or tribal areas have the high-speed internet needed to support remote care.
About a quarter of the 2,000 consumers surveyed had used some type of virtual care and 91% were satisfied with the experience. Up to 75% said they expect to use it even after COVID-19 eases off.
For physicians, the challenges to further adoption of telehealth include determining when telehealth is an appropriate option to in-person care, or getting reimbursed for services.
There was wide acceptance among both physicians and patients in telehealth uasge for prescription renewals.
Only 48% of physicians and 29% of patients were willing to use telehealth for their first meeting.
Across all age groups, a third or fewer said they would be willing to use a video visit for regular mental health check-ups.

The use of video consultations long term conditions has increased and includes management of diabetes, hypertension, asthma, stroke, psychiatric illnesses, cancers, and chronic pain. Video visits are also a good option for emergency eye care triage and management of a variety of acute conditions. Healthcare organizations will need to have proper strategies in place to balance virtual care and face-to-face care. Harvard Business Review recommends the following best practices to succeed with the hybrid care model in the era of Covid-19:

Develop criteria for triaging and scheduling patients for in-person or virtual visits: These criteria can be based on diagnosis, symptoms, or visit types (post-op, routine physical, etc.). Different specialties would have different criteria based on patients’ clinical needs.
Offer a blend of face-to-face visits and virtual care: Providers can offer a mix of in-person care and virtual care from the same clinical session and space. There should be strategies in place to move patients into and out of visits smoothly.
Establish technical functionality for virtual care: Providers need to have dedicated equipment, space, and focus to efficiently deliver telehealth in a block of time from any private, quiet space. This includes webcams on desktop or laptop computers for larger video screen size alongside the electronic health record (EHR) integrated video. Phones and tablets can be used as backup or as a backup when necessary.
Tele-interpreter service integration for phone and video visits: This is important to promote health equity. Interpretation is essential to provide quality health care for patients with limited English proficiency from all cultural and linguistic backgrounds.
Diversified technology toolbox: This implies using simple tools like text messages linking to live videos to allow as many patients as possible to benefit from virtual care. This can also help overcome any constraints on patients’ access to technology.
Fully involve care team: Medical assistants, schedulers and trainees, including students, residents and fellows, should be fully involved in implementing the hybrid care model. quality and safety data should be tracked to identify potential gaps or problem areas.

Healthcare facilities should be prepared to expand virtual care they are offering if the need arises. Monitoring virtual visit lag times between scheduling and visit date and visit length and other metrics is also important. Telehealth payment parity is also crucial to drive adoption and efficiency.

As healthcare providers focus on providing quality care by blending face-to-face visits and virtual consultations and building trust and nurturing patient relationships, outsourcing medical transcription can ensure accurate and timely EHR charting.

Quick Tips to Avoid Medication Error and Ensure Patient Safety

07-December-2020 Julie Clements Medical Transcription

Medication Error

The EHR was implemented to improve diagnosis, and reduce or prevent medical errors for improving patient outcomes. However, EHR is not totally fool proof and often fails to ensure accuracy, which leads to various mistakes including medication errors. The error rate can be reduced considerably with the support of EHR-integrated medical transcription service. According to a study conducted by scientists at the University of Utah Health, Harvard University, and Brigham and Women’s Hospital in Boston, electronic health records failed to detect up to one in three potentially harmful drug interactions and other medication errors (mentioned by Marla Milling in a forbes.com article).

What is Medication Error?

Medication errors are preventable events caused due to inappropriate use of medication. Healthcare professionals aim at providing the right medications and improving the health of their patients. But, unfortunately, medication errors are among the most common health-threatening mistakes that affect patient care. Such mistakes are considered a global problem which increases mortality rates, length of hospital stay, and related costs. According to a recent study in the Journal of Patient Safety, more than 30 percent of all EHR-related patient harm events cited in malpractice claims involve medication errors. Thirty-one percent of EHR-related claims involved medication errors, and 28 percent of claims involved diagnostic errors.

How Medication Error Occurs?

Medication errors can happen to any patient anywhere, including the patient’s own home or at the doctor’s office, hospital, pharmacy or senior living facility. Kids are especially at high risk for medication errors because they typically have different drug doses than adults.
Nurses who don’t follow the five rights of medication (right drug, right patient, right dose, right time, right route) can cause medication errors. Increased workloads can make nurses stressed and distract them, which leads to miscalculations and wrong dosage or medication to patients.
Drug calculations can be complex, and good mathematical skills are vital for safe drug administration.

Apart from increased patient workloads, other common causes of medication errors are:

Poor communication among healthcare professionals like doctors, nurses and other staffs.
Poor communication between healthcare professionals and patients.
Drug names that sound alike and medications that look alike, which can create confusion.
Medical abbreviations used in the medical record.

Preventing Medication Errors

The first and foremost step of ensuring proper medication is to have proficiency in drug calculation. When nurses have good pharmacologic knowledge, it will help them maintain proficiency in medication calculation.

Minimizing intervention in medication preparation can bring down medical errors significantly. Make sure to have enough staff to prevent staff exhaustion. Similarly, healthcare professionals must implement proper procedures for medication administration, including at least these five rights: right patient, right drug, right dose, right route, and right time.

Informing the patient about the medications and evaluating the effect of certain medications on the patient is also essential to avoid any harm to the patient.

Whenever you start a new medication, the following are some of the things that you should keep in mind.

Brand or generic name of the medicine
The purpose of the medication and the duration of its effect
The dosage of the medication and how long the medicine has to be taken
Recommendations in case of over dose
Food items and drinks that should be avoided while taking the medicine
Possible side effects of the medicine

Some other common mistakes to avoid

BConfusing eyedrops and eardrops: Always double-check the labels of eye and ear drops. If a medication says “otic,” it’s for the ears. If it says “ophthalmic,” it’s for the eyes.
Chewing non-chewables: Some medications should never be chewed, cut or crushed, because it may change how they’re absorbed by the body.
Cutting up pills: Split your pills only if your doctor or pharmacist has told you it’s safe to do so. Some medications shouldn’t be cut because they’re specially coated to be long-acting or to protect the stomach.
Using the wrong spoon: To get an accurate dose, use an oral syringe (available at pharmacies) or the dose cup that comes with the medication.

All the above-mentioned points should be considered carefully by any healthcare professional to ensure accurate medication administration. As mentioned earlier, wrong EHR records are also one of the main reasons for medication errors. To minimize electronic health record-related medical errors, healthcare professionals can invest in medical transcription services that can assist doctors in drafting accurate records, ensure safety of patients, and ensure the best healthcare outcome.

Incomplete Medical Records – Consequences and Solutions

03-December-2020 Rajeev Rajagopal Medical Transcription Outsourcing

Incomplete Medical Records

Complete medical records are foundational to quality healthcare. They provide a comprehensive picture of a patient’s health journey, support accurate diagnoses and treatments, and reduce the risk of medical errors. Most healthcare organizations choose to partner with a medical transcription company to ensure proper documentation of patients’ medical history, treatments, and progress. Given the importance of good medical record keeping, it is easy to understand the consequences of incomplete patient documentation.

Ensure accurate and complete records with expert medical transcription services.

Call (800) 670-2809 today!

“Missing information in the electronic health records (EHR) that hospitals and doctor’s offices keep is like a leaking pipe”, according to a study from UCF’s School of Global Health Management and Informatics. The article notes that studies show that missing data in medical records impacts hospitals’ revenue cycle and can lead to an average loss of about $5 to $8 million a year.

A study published in the Journal of General Internal Medicine revealed a link between incomplete medical notes and increased hospital stays and costs. Based on an analysis of more than 20,000 hospital admissions, the study found that incomplete documentation was associated with a 0.4-day longer hospital stay and an additional $1,386 in costs per patient.

What is an Incomplete Medical Record?

An incomplete medical record is one that fails to tell the patient’s whole story. Such records may miss critical data, such as diagnosis details, treatment plan, or necessary signatures, lacking clarity and specificity. Incomplete medical records compromise patient safety and care quality, leading to serious legal consequences for healthcare providers.

Under the Comprehensive Error Rate Testing (CERT) program, reviewers determine claims have errors when the medical documentation submitted is insufficient:

to support Medicare payment for the services billed
the services were provided at the level billed, or
the services were medically necessary

CERT audits determine insufficient documentation errors as including the following:

Incomplete progress notes (e.g., unsigned, undated, insufficient detail, etc.).
Unauthenticated medical records – no provider signature, no supervising signature, illegible signatures without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures.
No documentation of intent to order services and procedures – incomplete or missing signed order or progress note describing intent for services to be provided.

Not documenting the patient’s chief complaint (CC) is also indicative of incomplete documentation. The CC should be a succinct statement describing the symptom, problem, condition, diagnosis, or other factors that are the reason for the encounter, usually stated in the patient’s own words. Every level of patient history taken for an Evaluation and Management (E/M) service requires a CC.

Impact of Incomplete Medical Records

Incomplete medical records have far-reaching consequences, impacting both healthcare providers and patients. For providers, the effects include:

Misdiagnosis and Inappropriate Treatment: A lack of complete information may prevent physicians from fully understanding a patient’s condition, potentially leading to misdiagnoses and unsuitable treatment plans.
Increased audit risk: Incomplete medical documentation increases the risk of audits and investigations, which is costly and time-consuming.
Legal and Regulatory Risks: Failure to maintain comprehensive records can result in non-compliance with legal and regulatory standards, increasing the risk of lawsuits and penalties.
Financial Implications: Accurate medical records are critical for billing. Incomplete documentation can lead to billing errors and claim denials, disrupting the revenue cycle and causing financial losses.
Patient Safety Concerns: Missing details may contribute to treatment errors, endangering patient safety and outcomes.
Delays in Care: Inadequate records can slow down the care process, as medical staff must spend additional time gathering necessary information to proceed.
Affects Research: Incomplete medical records significantly affect research by introducing bias, reducing the reliability of study results, and potentially leading to inaccurate conclusions due to missing data.

Completing medical notes in a timely and accurate manner is crucial for providing quality patient care, ensuring legal compliance, receiving proper and timely reimbursement, and maintaining efficient workflow. So what are the factors responsible for incomplete medical records?

Incomplete medical records can result from:

Human Error: Healthcare professionals may unintentionally omit or misrecord information, leading to inaccurate records.
Technological Limitations: EHR system glitches or software issues can disrupt data recording, creating gaps in patient records.
Insufficient Training: Lack of proper training on documentation practices can lead to missed details or errors in records.
Overworked Staff: Heavy workloads and tight schedules may cause staff to rush or neglect thorough record-keeping.

Let’s now delve into what comprises a complete medical record and the best practices for ensuring its accuracy and comprehensiveness.

Complete Medical Records: Key Components and Best Practices

Typical medical records include:

Patient identification, contact information, and date of birth
Reasons for current visit
List of current and chronic ailments and diagnoses
Treatment plan, agreed actions, and recommendations
Current medications list with dosage
Documented allergies and sensitivities
Billing and health insurance details
Immunization records including past dates and outstanding needs
Instructions and educational info given to patient
Documentation of communication with the patient’s family/friends
Recommended return visit date

After the event, information should be entered in the record in a timely manner to relevant staff member. Any delay in the time of the event should be recorded. Other best practices include:

Standardized Forms: Using consistent forms ensures uniform documentation and minimizes the risk of missing key details.
Clear Documentation Guidelines: Establishing comprehensive guidelines helps ensure all necessary information is included and complies with legal requirements.
Staff Training: Ongoing training ensures healthcare staff are up-to-date on documentation standards, legal obligations, and software use.
Regular Audits: Conducting audits identifies gaps in documentation, improves practices, and ensures compliance with legal standards.

It’s also important to ensure objective comments, document any noncompliance, oral communications and informed consent, and state any objections regarding case management. The documentation should include the name and designation of the person making the entry and their electronic signature.

While EHRs are designed to ensure complete and accurate medical record keeping, most physicians find data entry a hassle. Outsourcing medical transcription to a reliable service provider is a practical strategy to ensure high quality, compliant documentation.

Outsource your medical transcription needs to improve record accuracy!

Benefits of Harnessing Telehealth for Chronic Disease Management

30-November-2020 MTS TEAM Medical Transcription Company

Telehealth

Chronic disease, which affects about half of all Americans at some point in their lives, poses a major problem and costs the United States an estimated $3.7 trillion annually, according to the American Action Forum. Chronic diseases such as heart disease, stroke, cancer, diabetes, pulmonary disease, and arthritis are common, costly, and preventable health problems. Reports suggest that patients with chronic diseases account for 81% of all hospital admissions. People with chronic conditions need continuous monitoring and ongoing care. Telehealth, supported by EHR-integrated medical transcription services, offers many benefits for chronic disease management. Telehealth expansion proved critical to care delivery with the onset of the novel coronavirus pandemic.

There are many benefits to using telehealth for managing chronic conditions:

Patients get ready access to providers and specialized care: With telemedicine, patients with chronic conditions can get appropriate care at the appropriate time and place. People in rural areas often lack easy access to sufficient medical care and may need to travel long distances to see a specialist. One-fifth of Americans live in areas that experience physician and healthcare specialist shortages (www.healthaffairs.org). Patients with mobility issues may find this even more challenging. Telehealth provides them with the care they need in the comfort of their homes, saving time and reducing the costs of transportation.
Remote patient triage and regular follow-up: By facilitating greater access to healthcare, telemedicine supports remote patient triage. If a new symptom develops, patients with chronic conditions can consult with their healthcare provider in real-time. This will allow the physician to modify treatment accordingly or instruct the patient to visit the nearest emergency room if the condition is serious. By facilitating timely treatment, telemedicine prevents chronic conditions from getting worse.

Live video and audio, mobile devices and other smart digital tools are used to manage patients’ conditions with regular follow-up. For instance, a patient’s ECG can be actively monitored in real-time using a remote cardiac device. The device constantly collects and compiles patient data and uploads to the cloud. With a summary report of the patient’s data, physicians can make an accurate diagnosis and prescribe an effective treatment plan.
Reductions in hospital admissions/re-admissions, length of hospital stay, and emergency department (ED) visits: Telehealth can reduce hospital readmission rates by improving the patient’s ability for self-care. It allows patients to communicate with their physician frequently after being discharged and discuss their symptoms and medications. Providers can share educational content with patients every day on the telehealth platform. Mobile devices and live video and audio can be used to remind patients to take their medication, maintain a healthy diet, exercise, and make other lifestyle changes which can improve the patient’s condition. Remote interventions help chronically ill patients care for themselves better. Frequent communication helps with proper treatment and reduces the rate of readmissions, duration of hospital stays, and ED visits.
Lowers costs: Telemedicine is a cost-effective way to deliver care for chronic conditions for both providers and patients. By triaging cases that can be addressed through a remote visit or until a regular office consultation, telemedicine reduces costs for patients. telehealth technology involves lower overhead costs than physical facility costs, which includes rent, salaries, and utilities. By allowing remote monitoring of chronic conditions, telemedicine lowers costs, improves efficiency, and increases revenue.

Experts believe that, even after the pandemic abates, telemedicine visits will continue to remain a part of the healthcare system in the future. In a recent survey from the COVID-19 Healthcare Coalition, up to 75% of healthcare providers said they would like to continue using telehealth for chronic disease management.

“Remote visits will become a permanent part of healthcare in the future because of both their efficiency and their convenience to patients,” Stafford wrote. “For patients with chronic diseases that benefit from regular follow-up, video visits provide a useful tool for maintaining high quality care. This is especially true for older patients with mobility problems or those patients who live far from their primary care physician,” noted Randall Stafford, lead author of a Stanford Medicine study published on Oct. 2 in “JAMA Network Open” (www.stanforddaily.com).

With a severe provider shortage and a growing gap in access to care for rural communities and most vulnerable populations across the nation, telemedicine can provide a cost-effective option to provide care to patients with chronic conditions. As the use of telemedicine expands, US based medical transcription companies will continue ensure quality EHR-integrated documentation solutions for remote patient consultations.

What are the Key Components Included in a Hospital Discharge Summary?

26-November-2020 Julie Clements Medical Transcription

Hospital Discharge Summary

A discharge summary refers to a clinical report prepared by health professionals that outlines the details of the hospitalization of a patient. Lack of discharge details, diagnosis information or patient’s health status in discharge summaries can lead to poor treatment plans. A discharge summary is an important document to have when discharging patients from a hospital. In addition to the essential medical information, the discharge summary may also include some other components such as a nursing discharge note, and hospital discharge paperwork. Physicians can rely on medical transcription companies to get accurate transcripts of discharge summaries and any other medical records.

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Research published by BMC Health Services Research in July 2024 recommends making the discharge summary a patient-centered tool that enhances communication and understanding between healthcare professionals, patients and relatives. The researchers noted that several issues have been identified related to the medical discharge summaries such as delayed transmission of the DS to the subsequently treating physician and others, low quality or lack of information, lack of consistent formats, lack of patient understanding, and insufficient training for medical students in writing these summaries. They highlight the importance of transferring all relevant information in a discharge summary to ensure a safe patient discharge from hospital. The study states that it’s essential that the patients understand the discharge summary and recommend simple measures to improve content readability for patients as well as healthcare providers.

A structured and accurate discharge summary is crucial –

For transferring information between the hospital care team and aftercare providers
To help physicians quickly identify how to respond to the patient’s hospitalization
To promote patient safety
For legal purposes to show evidence of patient care, if errors are made

The discharge report must give a summary of everything the patient went through during the hospital admission period – physical findings, laboratory results, radiographic studies and so on.

Significance of Discharge Summary

There are various reasons why discharge summaries are essential.

Clinical Accuracy: By providing a thorough description of the hospital stay, they reduce the possibility of clinical errors during care transfers.
Continuity of Care: For specialists and outpatient providers, they give guidelines for continued care, which is essential.
Communication Improvement: They make it easier for different healthcare organizations that provide patient care to exchange reliable information.

Effective documentation of discharge summaries improves health outcomes while streamlining patient management.

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Main Components of a Discharge Summary

Here’s a look at the essential components of a well-structured medical discharge summary, each crafted to capture vital aspects of the patient’s care journey. These components ensure that healthcare providers have a complete, clear record of the patient’s condition, treatments, and necessary follow-up care, providing a seamless bridge between hospital and post-discharge settings.

1. Reason for Hospitalization: Understanding the cause of hospitalization helps comprehend the entire treatment plan for the patient. It enables medical professionals to decide on the patient’s treatment strategy. It serves as a foundation for foreseeing any issues and putting preventative measures in place both before and after the hospital stay.
2. Diagnosis: The basis for the entire treatment approach is a proper diagnosis. It assists in choosing the right treatments and drugs. A proper diagnosis can also help in predicting the disease’s probable course, directing follow-up care and observation. It also helps the patient and his/her family create reasonable expectations about the prognosis and potential results.
3. Findings: Together with imaging and lab results, these findings provide insight into the patient’s health and response to therapy. Significant findings may also draw attention to any unforeseen side effects or disorders that could affect the course of treatment. They offer crucial information for assessing the effectiveness of current treatments and figuring out what has to be changed for the best possible patient results.
4. Understanding Test Findings: Test findings can help determine whether the treatment strategy is sufficient or needs to be modified. Furthermore, routine evaluation of these data enables proactive interventions and improved patient care by assisting medical professionals in anticipating possible dangers or consequences.
5. Procedures and Treatments given: These can include anything from physical therapy and surgery to the use of medical gadgets or drugs. A better understanding of these treatments and measures can help the patient and their caregivers recognize the value of follow-up care and better follow post-discharge recommendations. A thorough list of all the drugs the patient has been given, together with dosages and frequency of administration, is also included. Since it enables the primary care physician or the next healthcare provider to continue or adjust the medication regimen as needed, this information is essential for guaranteeing continuity of treatment. Additionally, it also makes it easier for the patient and their caregivers to comprehend and follow the prescription regimen, which promotes the best possible health results.
6. Condition of the Patient at Discharge: A summary of the patient’s health at discharge is provided by the discharge condition. The state of the patient upon discharge can reveal information about their immediate medical needs after release as well as the efficacy of the treatment they received. During the follow-up care time span, it also acts as a baseline for tracking any changes in health condition.
7. Post-discharge Treatment: These guidelines address food, exercise, medicine administration, and warning indicators. Depending on the patient’s condition, the dietary recommendations may include certain diets or limitations. Guidelines for physical activity strike a balance between the need for rest and recuperation and preserving general health, and warning indicators assist patients and caregivers in spotting possible problems or relapses early.
8. Physician’s Signature: The accuracy and completeness of the facts in the discharge summary are verified by the doctor’s signature. The credibility of the information provided is ensured by this signature, which attests to the doctor’s evaluation of all the details. Also, it encourages a greater degree of effort and completeness in recording patient treatment by holding the doctor accountable for the patient’s care plan.

Failure to report any patient discharge condition details may affect patient safety. It’s important for a discharge summary to include key components such as nursing discharge note and hospital discharge paperwork. Reliable medical transcription services can efficiently meet physicians’ patient record documentation needs to a great extent.

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