Medication Reconciliation – A Key Consideration for Improving Patient Handoffs

23-December-2019 Rajeev Rajagopal Medical Transcription

As their condition and care needs change, patients are moved between health care practitioners, settings, and home. Medical transcription outsourcing helps physicians provide proper documentation when transitioning a patient to a new source of care. Transitions in care include hospital admission, transfer from one unit to another during hospitalization, or discharge from the hospital to home or another facility. At times of these transitions in care, patients are often prescribed new medications or have changes made to their existing medications. Medication errors are a common safety issue during patient handoffs or transfer. These errors can be avoided through accurate medication reconciliation processes.

The Joint Commission defines medication reconciliation as the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. Inadequate reconciliation in handoffs during admission, transfer, and discharge of patients can follow the patient throughout their treatment and cause harmful medication errors. According to the World Health Organization (WHO), more than 40% of medication errors are believed to result from inadequate reconciliation in handoffs during hospital admission, transfer and discharge, and of these about 20% are believed to cause harm.

In a recent Becker’s Hospital Review poll on the patient safety issue clinicians would fix overnight, one of the respondents identified medication reconciliation as the top concern.
“It’s (medication reconciliation) been a problem my whole career. Nationwide, about one-third of patient harm is related to medication. It’s a difficult nut to crack because there are so many different caregivers involved in the process across the care continuum. There’s also been a proliferation of new drugs, and providers are not as familiar with all the medications. It’s hard for them to keep up, especially when patients are on a lot of medications,” Stephanie Jackson, MD Senior vice president and chief quality and clinical value officer at Scottsdale, Ariz.-based HonorHealth told Becker’s.

Having proper medication reconciliation processes in place is crucial to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. The five steps in the process of medication reconciliation are:

Make a list of the patient’s current medications
List the medications currently required
Compare the lists
Create a new list based on the comparison, and
Communicate the new list to the patient and caregivers

Medication reconciliation has to be done at every transition of care in which new medications are ordered or existing orders are rewritten. There are many reasons why medication reconciliation should receive greater attention:

Medication reconciliation processes can vary widely across healthcare settings. Lack of standardization of the process of medication reconciliation results in great variation in the historical information gathered.
There is often duplication of data collection by nurses and physicians when taking medication histories, documenting them in different areas in the chart, and hardly ever comparing and addressing any discrepancies between the two histories.
Physicians may not get sufficient time to perform medication reconciliation at the patient consult due to lack of time.
Medication reconciliation allows physicians to bring up the topic of medication adherence which is a major problem among many patients.
An AHRQ survey found that EHR systems can maintain active medication lists and order medications, but many systems lack functionality to support electronic medication reconciliation or are unable to capture information needed to report medication reconciliation quality measures.
Clinicians’ focus on EHR documentation during the consultation often leads to less time for the patient and affects medication reconciliation.
Lack of EHR interoperability may lead to providers missing critical information on medication history.
Proper medication reconciliation is crucial to prevent patient harm and readmission.

Medication reconciliation is incorporated into National Patient Safety Goal (NPSG) #3, “Improving the safety of using medications.” The Joint Commission recognizes that the best medication reconciliation requires a complete understanding of what the patient was prescribed and what medications the patient is actually taking. The 2019 National Patient Safety Goal has a new requirement that requires organizations to inform the patient about the importance of maintaining updated medication information. The elements of performance for medication reconciliation in NPSG are as follows:

Obtain and/or update information on the medications the patient is currently taking.
Define the types of medication information (for example, name, dose, route, frequency, purpose) to be collected in different settings and patient circumstances.
Compare the medication information the patient is currently taking with the medications ordered for the patient in order to identify and resolve discrepancies.
Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she leaves the organization’s care.
Explain the importance of managing medication information to the patient.

In addition to medication reconciliation at points of transition, it is necessary to maintain a patient medication list in primary care records. There are significant logistic challenges involved especially in the case of patients seeking treatment from multiple healthcare providers. Good practice requires using a team-based approach involving the resident, care and nursing staff, pharmacists, medical practitioners, and medical transcription service provider.

Study identifies Misinterpretation of CT Scans as Key Cause of Radiology Malpractice Claims

19-December-2019 MTS TEAM Medical Transcription

Radiologists utilize X-rays, MRIs, CT scans, ultrasounds and various other techniques to visualize the body and help diagnose diseases and injuries. Medical transcription companies providing radiology transcription services help them document the results of these radiologic studies or procedures, and produce different types of reports. However, a major reason for litigation against radiologists is the failure to communicate results properly. Radiology Business recently reported on a new analysis by physician-led malpractice insurer the Doctor’s Company which identified misinterpretation of scans, especially computed tomography (CT) scans, as the leading cause of patient injury in diagnostic radiology.

Published the first week of December, the Doctor’s Company’s study covered nearly 600 malpractice claims against diagnostic and interventional radiologists, closed between 2013 and 2018. According to the analysis:

about 78% of injuries in cases against diagnostic radiologists were the result of image misinterpretation
In most cases, the injury was an undiagnosed malignancy
Most of the misinterpretation (about 78%) occurred with CT scans
“Technical performance” accounted for about 76% of claims against interventional radiologists
Faulty technical performance included patients suffering poor outcomes from invasive procedures
While the appropriate procedure was performed correctly in 65% of invasive procedures, the patient was dissatisfied with the outcome
11% of claims against interventional radiologists were due to poor technique or treating the wrong site
18 percent of injuries are associated with poor communication between physicians

One key takeaway for radiologists is the need to improve information exchange among providers and with patients.

According to study author Darrell Ranum, vice president of patient safety and risk management with the Doctors Company, “The findings on interventional radiology indicate the importance of communication between the radiologist and the patient prior to the surgery or procedure”. It is critical that the radiologist clearly explains the chances for injury during the informed consent process and ensures that the patient understands the risks.

The study recommended several risk mitigating strategies that radiologists can use, such as equipment tracking inspections, monitoring updates and settings, ordering repeat studies if views lack quality, and having a defined process for identifying and analyzing diagnostic errors.

RSNA 2019 has stressed that patient-centered care means that radiology must make reports more digestible for patients (www.healthimaging.com). A study led by Penn Medicine researchers who crowd sourced the question as to whether patients understand radiology reports found that less than half the respondents (patient surrogates) correctly interpreted the reports.

Typically, the reader of the radiology report is the physician responsible for providing direct patient care. The radiology report contains the radiologist’s interpretation, discussion, and conclusions about the radiologic study. The report poses a liability risk if it fails to effectively communicate important information about the patient’s condition. The healthcare provider, who depends upon the report to make decisions concerning patient management, should clearly understand the report. To meet this requirement, the report should be brief, clinically relevant, and consistent. Effective report writing means that pertinent information about the diagnosis, condition, response to therapy, and/or results of a procedure performed, will be transmitted clearly and concisely. Structured reporting is advocated as a means to improving the quality of radiology reports and patient management.

The radiology report also communicates information to patients and their family members. Many healthcare institutions make radiology reports available through patient portals. Radiological screening programs, such as breast screening programs, typically communicate results directly to patients. Experts say that the language used must be comprehensible to patients.

To reduce risk of malpractice suits, radiologists need to ensure accurate, timely, appropriate, and documented communication. Medical transcription outsourcing can help radiologists ensure that there are no mistakes in the reports, including typos and dropped words. To ensure proper evidence, the radiologist’s thought process as well as all consultations and discussions held should be documented. Experts say that radiologists can also minimize risks of misinterpretation by avoiding reading studies and modalities in which they lack proper training and obtaining follow-up consultation with subspecialists (radiologybusiness.com).

Short, Informative Consult Notes can Improve Medical Record Quality and Patient Care, say Experts

16-December-2019 Rajeev Rajagopal Medical Transcription Company

Until the advent of electronic health records (EHRs), health care providers relied largely on medical transcription companies to document office visits and consultations. Today, these outsourcing companies provide digital medical transcription services, converting audio recordings of physician dictation into accurate and well-formatted notes for the EHR. Clear and accurate medical notes support clinical decision-making and patient care. Experts have made several recommendations to improve the consult note in the electronic record system.

A medical consultation allows the physicians to assess the patient’s problems and concerns and to diagnose their illness. Patients are asked questions about their condition and allowed to provide answers in their own way. Many patients have more than one concern to discuss. Best practice is to avoid interrupting the patient as this may prevent disclosure of full information. Once the problems have been discussed, the physician should repeat a summary back to them to ensure that they have understood the patient correctly. Many physicians use a medical transcription service to maintain eye contact with the patient and avoid becoming too immersed in EHR data entry.

However, experts point out that notes that physicians write to document medical consultations are too long. This is because the Center for Medicare and Medicaid Services (CMS) and other third-party payers tie their assessment of the amount of work done, and hence the valuation of the physician’s work to detailed documentation. In an article published in Cleveland Clinic Journal of Medicine in 2015, K.K. Venkat, MD describes the problem as follows:

To meet paper requirements, physicians include detailed documentation of the history (present, past medical, past surgical, medications, allergies, social, and family), review of systems, and physical examination in the consult note.
The above information is already in the medical record and repeating it in the consult note leads to duplication of information.
As this part of the consult note is hardly ever read, time spent on repeating information is wasted time.
EMRs have made it easier for the provider to create lengthy consult notes by checking boxes in templates and copying and pasting from other parts of the electronic record.
The educational value of the consultation depends on consultant’s critical reasoning, but the assessment and recommendations section in the consult note is too short.

The article recommends keeping consult notes in the EHR “short and sweet”.

A 2015 Medscape report also highlighted the features of succinct and effective consult notes. According to the author, the consultant’s note that addresses patient care issues, should be concise, brief, not duplicative, logically structured, and offer educational value. However, the problem is that such a note would not be “optimally reimbursed” by today’s payers. According to the article, payers should recognize and reward critical reasoning skills rather than the length of the consult and the ability to copy and paste or reproduce information. Done correctly, a consultant’s note can be educational, drive the requesting and the providing physicians or other staff to think comprehensively, improve patient care and outcomes, and reduce unnecessary testing or treatment.

A study published in The American Journal of Medicinein 2018 noted that shortening EHR case notes can ease the EHR burden and mitigate physician stress and burnout. According to the researchers, EHRs contribute to lack of enthusiasm, lack of accomplishment, and cynicism – the three main causes of physician burnout (www.healthleadersmedia.com).

The researchers said that case notes can be shorter without compromising the quality of the information and recommended the following best practices for taking shorter case notes:

Record the patient’s presenting complaint and all relevant data that helps the physician formulate the differential diagnosis (DDx) and a plan for concluding the visit.
Relevant data can include testing, consultation, procedures, or medications.
Any additional documentation can affect the quality of care as the physician has to enter data and populate the record with templated information that complicate and mask the key patient care issues the next time a physician sees the chart or the patient.
Take notes while asking questions and look at the patient while performing EHR data entry.
Have a template that auto-populates medications, vital signs, and simple exams.
Use separate templates for children and gynecological exams.
Skip templates and manually enter problems or assessments with alternative diagnoses when making assessments or diagnoses.
State why preferred and alternative diagnoses are possible, which will help explain diagnostic reasoning when other providers view the record.

“The hours spent cloning notes in a mandated doctor-computer relationship leaves the physician unable to experience the best part of being a doctor… Rational people should feel cynical if the institutional accomplishment for the day is to produce 20 cloned medical records,” wrote the researchers.

2020 New Year Resolution Ideas for Doctors

12-December-2019 Julie Clements Healthcare News

It is quite common for anyone to make New Year resolutions and some may follow those, while others drop them on the way. Physicians can also take certain good resolutions and ensure that those are faithfully kept. Ensuring accurate documentation is a resolve that physicians can efficiently meet with the support of medical transcription companies. Other resolutions doctors can make could be to improve care for patients, improve patient access to healthcare and thus improve the growth of their own practice, and to engage better with co-workers and patients.

Here are a few New Year resolutions for physicians –

Stay up-to-date with the changing healthcare trends

Take efforts to be aware of the trends that will impact healthcare in the future and prepare for the same. For instance, in 2018 telemedicine-based treatment model was the trend. By integrating telehealth into their practice, physicians could improve their workflow by expanding their services and by providing greater accessibility to patients. Many medical specialties including radiology, ophthalmology, psychiatry, pathology, cardiology and dermatology used this innovative treatment mode to improve their reach, accessibility as well as quality of care.

Also, stay more informed about emerging health IT safety–related goals and priorities. Key tech trends that may impact healthcare in 2020 include Natural Language Processing (NLP), Internet of Things (IoT), Machine Learning (ML) and Blockchain Technology.

Create a paperless environment

Even with the adoption of EHR and other advanced systems, many hospitals are still relying on paper for documentation and for patient registration. Though extinguishing all sorts of paper from a hospital is not an easy task, it is not impossible. In 2020, consider reducing paper consumption mainly to protect your environment. Patient registration can be done electronically. Cloud computing is an ideal option, as it covers everything from storing backups of important data remotely to running all office systems in the cloud. Cloud storage will help to simplify and automate IT systems.

Improve your communication with patients

Along with improving patient care, compliance, and satisfaction, better communication also helps to streamline certain office functions like patient scheduling and insurance verification so that staff can communicate financial responsibilities to patients and engage them at the outset itself. Earlier, physicians’ complaint was that EHR entry is consuming their quality time that could be spent with their patients. EHR-integrated medical transcription services are now available to help physicians in the successful adoption of Electronic Health Record systems.

Read our blog on how important proper physician-patient communication is to build strong rapport.

Strictly follow patient safety goals

Train your entire staff to follow all the rules related to patient safety such as – making sure that the correct patient gets the correct blood during a blood transfusion, labeling medicines that are not labeled before a procedure, recording and passing along correct information about a patient’s medicines, making sure that alarms on medical equipment are heard and responded to on time, using proven guidelines to prevent infection after surgery and making sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.

Studies Show a Rise in Vaping Related Illness in Central Florida

09-December-2019 MTS TEAM Healthcare News

Effective communication between patients and their healthcare providers ensures better patient care, and can make a positive influence on health outcomes while increasing patient satisfaction. It leads to greater patient understanding of health problems and treatments available. Better communication also helps patients to reveal their bad habits like alcohol consumption, smoking, drug addiction etc. To gain more quality time with patients, doctors depend on dedicated solutions such as EHR-integrated medical transcription services. In keeping with the trend of timely communication with the patient population, doctors in Florida are warning teens about the dangers of e-cigarettes as the Florida Department of Health reports that there has been one death and 39 confirmed cases of lung injury associated with vaping in the state as of October 1.

According to a report by Orland Sentinel, Cynthia Gries, the medical director of lung transplant program at AdventHealth, the message about the harmfulness of bad habits such as vaping should be given right from a very young age. She added that young children should be made to realize the negative repercussions of vaping. In the US there are more than 1,000 cases that have been reported to the Centers for Disease Control and Prevention from 48 states and 1 U.S. territory this year and there have been 18 deaths in 15 states. Majority of the patients that are involved in vaping are men who are below 35 years of age who use products that contain THC which is a high marijuana chemical. Health officials at the CDC and the Food and Drug Administration have urged the public to avoid vaping altogether.

E-cigarettes is a booming industry that remains largely unregulated in the United States and it continued to gain popularity after the introduction of JUUL, a popular brand of e-cigarettes and flavors such as candy, fruit and chocolate. A recent federal survey showed that around 28 percent of high school students reported using e-cigarettes this year, compared with 21 percent last year. Researchers have found intermittent cases of lung injury over the years due to vaping and they are trying to find out what harmful product is causing the lung injuries.

Over the last few months, doctors of Orlando area analyzed patients who landed in the ER and eventually ICU due to vaping. There have been at least four cases at Orlando Health Arnold Palmer Hospital for Children, two at Nemours Children’s Hospital, about seven at Oviedo Medical Center and a handful more at AdventHealth Orlando. Most of these patients are teenagers and young adults. A pediatric critical care physician at Arnold Palmer Hospital, Dr Jenna Wheeler, encourages parents to educate themselves about the e-cigarettes and vaping and then have a conversation with their teens.

Symptoms of lung injury from vaping begins with nausea, vomiting, diarrhea along with shortness of breath. According to a pulmonologist, Dr. HadiChohan at Central Florida Pulmonary Group, who treated around eight to 10 patients at area hospitals in recent months, the patients’ condition worsens quickly after being admitted, but then they do improve over a period of 48 hours. They may have to remain hospitalized for approximately seven to 10 days or more before they can be discharged.

From the above details we can understand that the use of e-cigarettes can lead to respiratory issues. The CDC has taken initiatives to discourage the use of e-cigarettes and vaping products.

Embarrassment and the feeling of being judged are the main reasons why patients hide their bad habits from doctors. Doctors have to take great effort to win the patient’s confidence so that he/she talks openly about the bad habits or addictions they have. Keen observation and accurate documentation of the patient’s condition, preferably with the support of medical transcription companies, are vital to provide appropriate care and treatments. The important consideration is the time doctors get to spend with the patients. Only this can help build rapport between the patients and doctors and persuade patients to share their concerns openly with their doctors. Casual chats with patients help them open up more about their health condition and habits. When it comes to addictions like smoking and alcohol, doctors can provide an effective care and support system to their patients by listening to them patiently and understanding the root causes of their health problems.as EHR-integrated

Technological Advancements Help Build an Effective Healthcare Eco System

05-December-2019 Julie Clements Healthcare News

Integration of medical transcription service and EHR helps physicians focus more on providing better patient care. Improving patient care has become a priority for all health care providers with the overall objective of achieving a high degree of patient satisfaction. Health facilities often struggle to provide the rapid emergency care to the patients. Common causes include inadequate or unhygienic infrastructure; lack of competent, motivated staff; lack of availability or poor quality of medicines; poor compliance to evidence-based clinical interventions and practices; and poor documentation and use of information. Healthcare providers need to focus on delivering high-quality healthcare and fostering patient safety in order to create a positive patient experience.

To serve better, healthcare industry has introduced various apps. Medical apps and additions of smart phones have transformed the medical industry and there is nothing that is not possible with a smart phone. Today everyone has access to smart phones and with every year its usage is increasing drastically. This has led to the emergence of apps that help in booking appointments, setting medication reminders etc. This greatly helps people living in remote areas.

KnowDi is a healthcare app that serves as one stop solution for patients as well as doctors. It has been developed with a deep understanding and it is a collaborative healthcare ecosystem that keeps the patient at the centre while benefiting the entire ecosystem. KnowDi is a centralized healthcare platform that connects all the important components of the ecosystem – patients, doctors, hospitals, labs and pharmacies.

This app incorporates all stakeholders in the value chain and also serves a complete solution for patients. Patients can benefit from all kinds of services such as doctor appointments, delivery of medicines, diagnostic tests, or managing their medical history. They also offer Ayurvedic doctors as an alternative method of healthcare. Another feature of KnowDi is that it provides data management system. One of the biggest keys to successful outcomes in healthcare is access to complete and comprehensive medical data that is lacking at the present. The entire platform is built in such a way that it helps patients to store and manage their medical history in a secure and confidential manner.

A secure database for medical history

KnowDi has a special and highly secure database where patients can store their medical data including diagnostic tests, prescriptions for medication, X-rays, doctors’ diagnoses etc. When a patient books an appointment through the app, the doctor can get access to the patient medical history, only if the patient decides to give access via the app. Having access to medical history helps physicians to provide the right treatment plan to the patients.

KnowDi also aims at expanding the customer base of local businesses like chemists. They have a hyper-local delivery model and patients get medicines from pharmacies that are located within 2 km of their home. KnowDi app has already tied up with 22 hospitals and more than 50 pharmacies with over 750 physicians. With the data management tools, doctors can access the comprehensive medical history of the patient at the click of a button, making accurate and timely diagnosis much easier. The app also provides real-time monitoring of patients.

Physicians often overwork and get pulled in many directions. So physicians must be equipped with right tools for streamlined processes. Smartphones and medical apps help both patients and doctors to coordinate better and work towards creating a better healthcare eco system. Today many healthcare organizations are utilizing EHR-integrated medical transcription services for timely and accurate medical documentation. Medical transcription companies offer customized services at affordable rates and also help physicians and other healthcare professionals to focus more on providing quality patient care and service.

Vision 2020 – Strategic Planning for Medical Practices

02-December-2019 Rajeev Rajagopal Medical Transcription Company

As a medical transcription company that helps physicians manage their demanding documentation tasks, we are aware of the problems of running a practice. While the adoption of electronic health records (EHRs) allows clinicians to deliver better care, improve efficiency, and control costs, new technology presents many challenges. With 2020 around the corner, physicians need to take a look at their past experiences with health IT, revenue cycle management, and other matters, and set realistic goals for a stronger year ahead. Here are six strategies to prepare your practice for 2020:

Review your business plan: With changes in the way care is delivered, value-based initiatives, enhanced technology, and the ever-changing regulatory environment, nothing is possible without solid planning. Most practices would already have a plan in place for 2020. Take time to review your plan and prioritize your most important goals. Review important things such as patient volume, charges, collections, accounts receivable and overheads. Do a S.W.O.T. (strengths, weaknesses, opportunities and threats) analysis. Having a clear idea about where you stand will help you determine what you should prioritize in the coming year(s). Put your business priorities down in writing.
Set practical goals: A practical goal is one that is achievable. Identifying your obstacles and challenges can help you set realistic goals. Potential challenges may include attracting and retaining patients, cash flow problems, hiring good employees, and better training for staff. Once the key concerns are identified, it will become easier to overcome them and set attainable goals. Things to remember when setting goals:
- Focus on two or three meaningful goals
- Set engaging but pragmatic goals
- Review goals regularly
- Set a timeline to achieve them
Understand technological advances and consider adoption: As a Physicians Practice article notes, virtual visits are becoming an everyday reality. The American Well 2019 physician survey found that virtual visits increased 340 percent in recent years. Telemedicine is cost-effective, offers convenience and expands access to care, and builds closer relationships with patients. With a promising reimbursement landscape and the industry’s vision to expand telehealth use, the stage is set for telehealth’s huge growth in the future. Practices that do not offer access to virtual care need to consider if it is a viable addition, or face the risk of losing patients who expect telemedicine services. Machine learning, AI, and apps are other technologies impacting healthcare and practices need to consider whether investing in these options can benefit them and their patients.
Encourage staff involvement and input: In addition to physicians and managers, a medical practice team would include nurses and other clinicians, front office representatives, medical transcription service providers, billing and coding staff, and other ancillary service providers. Developing a strategic direction for the practice would require input from everyone. A recent Medical Economics article notes that planning discussions should foster rigorous discussion and questions about the direction of the practice. Airing divergent perspectives, information and ideas is crucial to reach a consensus. Frequent and effective communication is especially important to build trust, share accountability, and foster a culture to achieve the shared vision. Each individual should understand their contribution and work towards to achieving the goal – both in their own job and as a member of the team. Physicians should empower their staff and ensure they have the tools and resources to achieve their objectives.
Review and update your strategic plan: Since the healthcare environment is constantly evolving, you may need to refine specific strategies and goals to meet changing circumstances during the year. Best practice is to proceed with the strategic plan as designed, but review it periodically to determine things that need to be changed, and be flexible to implement modifications as necessary. Deviating from the plan is a constructive way of rethinking original goals and setting new ones.
Have a system to track progress: Strategic planning also requires have a robust system in place to track and analyze progress and performance. Tracking and monitoring outcomes on a regular basis will help you understand if goals can be achieved.

One inevitable trend in 2020 and beyond is role that technology will continue to play in transforming the healthcare industry. However, as a recent Physicians Practice article reports, one key take-away from health technology is that it has not yet improved the time that physicians spend with patients. According to the Annals of Internal Medicine, doctors spend, on average, just 27 percent of their time treating patients and more than 70 percent of their time on administrative, non-billable tasks, such as answering patient calls and returning messages or replying to emails. EHR data entry is another time-consuming task that affects the patient encounter and also leads to physician burnout and stress. Outsourced medical transcription services are the answer to these concerns. A reliable HIPAA-compliant medical transcription company can ensure accurate and timely EHR-integrated dictation reports.

As you put 2020 objectives in place, it’s important to remember that there are no hard and fast goal-setting rules that fit every practice’s needs. The bottom line: set realistic goals and provide your team with the information and tools needed to achieve them.

Perspectives on the Use of Image-Rich Radiology Reports

28-November-2019 MTS TEAM Radiology Transcription

Radiology reports are vital for patient care. Some clinicians can interpret imaging studies on their own, but a report prepared by a radiologist can result in better patient care as it provides more accurate and comprehensive interpretation of the findings. Medical transcription companies help radiologists ensure accurate interpretation of imaging studies and appropriate communication of the findings to attending physicians in a timely manner.

Various studies have reported on benefits of blending images and radiology reports for referring physicians. Researchers have also analyzed clinician preferences in terms of format, content, length, and turnaround time. Musculoskeletal (MSK) radiology, a sub-specialty of diagnostic radiology, plays an important role in evaluation and management of patients with a wide variety of injuries. It involves the imaging of the bones along with cartilage, connective tissue, joints, ligaments, muscles and tendons. Musculoskeletal imaging includes:

Digital radiography (filmless x-ray)
Fluoroscopy (continuous x-ray that shows movement of the body part)
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Sonography (uses sound waves to generate an image)
Ultrasound

Advancements in ultrasound and MRI allow superior visualization of tendons, ligaments, and cartilage, increasing the importance of medical imaging in musculoskeletal injury diagnosis and treatment. Let’s take a look at some recent perspectives on image-rich radiology reports and their value for the referring physician.

According to a study published in the Journal of the American College of Radiology in May 2018, clinicians view radiology reports more often than the actual images. This suggests that radiologists’ interpretations are more valuable, wrote researchers from Johns Hopkins Medical School in Baltimore. The team analyzed 7,438 studies and found that radiology reports were examined in 85.7 percent of cases and imaging reports were viewed 53.2 percent of the time (www.healthimaging.com).

An August 20, 2019 study published in the Journal of Digital Imaging reported that integrating an audio/visual reporting tool into an emergency department’s musculoskeletal workflow can improve communication between radiologists and referring providers while making imaging findings easier to interpret. All of the participants (attending orthopedic surgeons in the emergency department) said the audiovisual report improved their understanding of complex cases. The audio-visual report enabled speedy evaluation and provided quality information for ordering physicians, which in turn, improved decision making, especially in complex cases.

Health Imaging cited the authors as saying, “Providing clinicians with a supplemental audiovisual report could deliver an engaging experience similar to an in-person consult with the radiologist focused on simplification of a complicated case… Those videos contents could be viewed at the convenience of the ordering provider to minimize disruptions in workflow and retain the radiologist’s essential role in a multidisciplinary team.”

Recent research, which sought to analyze the viewing habits for images and reports, found that ordering clinicians across most specialties utilize musculoskeletal (MSK) radiology reports much more often than images. The findings of the study, as summarized in a Health Imaging article, are as follows:

Clinicians viewed MSK reports alone or in addition to the images 96.3% of the time
In 51.9% of cases, radiology MSK reports were viewed alone
Providers accessed images by themselves without viewing the attached report only 3.7% of the time
CT and MRI reports (without images) were viewed most often (in 68.3% of cases)
MRI reports were accessed in 57.3% of cases and radiography reports in 48.3% of situations
Orthopedists ordered the highest number of MSK studies and accessed reports 99.2% of the time; they viewed reports alone 54.5% of the time and looked at images in only 0.8% of cases
Radiology MSK reports were reviewed 96.3% of the time, twice as often as images (48.1%)

The researchers concluded that physicians relied more on the radiologist reports rather than the images.

Image-rich radiology reports can improve communication and also have the potential to boost the work flow efficiency of referring physicians. Today, radiologists need to be focused on delivering meaningful radiology reports that allow clinicians to provide value to both referring providers and patients. Radiology transcription services are a great support when it comes to delivering well-organized, accurate, and meaningful findings radiology reports.

Five Common Nursing Errors and Strategies to Prevent Them

25-November-2019 Julie Clements Medical Transcription Company

Operating in a fast-paced, unpredictable environment, healthcare workers experience greater stress at work and more negative outcomes of stress than professionals in other fields. Medical transcription companies are focused on helping them with their arduous documentation tasks. However, high workload, lack of experience and support systems, medical negligence, miscommunication, and poor collaboration can lead to nursing mistakes. Medical errors pose a threat to patient morbidity and mortality and are a serious and costly public health problem. Let’s take a look at the common areas where errors in nursing occur and how to avoid them.

Medication administration: According to the National Medication Errors Reporting Program, medication errors kill one person every day in the US. When it comes to medication, nurses shoulder a lot of responsibility as interact directly with the patient, and have to interpret instructions and administer medicine correctly. However, mistakes can occur during the process of dispensing and administering medication such as inappropriate dosage, errors of omission, wrong medication, or wrong route of administration. Taking the following steps can help prevent these errors:
- Using a bar coding medication scanning system to confirm the six medication rights: correct medication, patient, route, dose, time, and documentation
- Actively consulting with the pharmacist and other team members to ensure all look- and sound-alike drugs are stored in a way that they can be distinguished
- Double checking all high-alert medications with another clinician
- Know the medications administered, including adverse reactions
- Informing the patient about the medication administered and the reason for it
- Asking the patient about any reactions or allergies before administering medication
- Ensuring that the patient’s medication list is consistently updated
Infection: As patients have a compromised immune system, they are susceptible to infections caused by bacteria and pathogens present in hospitals. According to the CDC, approximately 1 in 31 patients has at least one Healthcare Associated Infection (HAI) on any given day. The medical setting needs to be kept clean and healthy by following proper infection prevention protocols. Steps that nurses should take to minimize patients’ risks of infection include:
- Hand hygiene – washing hands frequently and wearing gloves when touching a patient
- Using chlorhexidine for skin preparation to prevent surgical site infection
- Sterilizing and sanitizing equipment
- Following guidelines for central line use and removal
- Cleaning and removing catheters in a timely manner and avoiding long-term catheter use as far as possible
- Following specific checklists to prevent central line bloodstream infections ventilator-associated pneumonia, etc.
Documentation: With their heavy workload, nurses find it difficult to document major events and changes in patient condition. Charting should be done accurately and in a detailed and timely manner. This is important to ensure that other clinicians have all the information they need to treat the patient. Any adverse events should be immediately reported. In addition to signs and symptoms and healthcare provider notifications, all information given to patients and/or their caregivers should be documented. Handwritten notes should be clear and legible. A medical transcription service provider can provide valuable support when it comes to ensuring high quality EHR documentation.
Falling accidents: The Agency for Healthcare Research and Quality (AHRQ) estimates that, every year, about 700,000 to 1 million people in the US experience a fall in a hospital. More than one-third of in-hospital falls result in injury, including serious injuries such as fractures and head trauma, according to the agency. Even the slightest fall can result in serious injuries and cause legal problems for the hospital. Patients can fall when they are weak or try to get up and move around on their own after a procedure. The common reasons for hospital falls include negligence by nurses, staff shortage, improperly trained staff, lack of/not following proper patient lifting techniques and hazards like spills, broken tiles or loose rugs. The best way for nurses to prevent patient falls is by constantly checking up on those at a higher risk and making sure that they have everything they need within reach. Hallways, patient rooms, and recreation areas should be inspected regularly for problems that could patient slips and falls.
Equipment-related injuries: Patients can suffer injuries as a result of the malfunctioning of hospital equipment. MRI, IV pumps, heart monitors, anesthesia machines and mechanical beds can fail they are not working or used properly. Training nurses on proper and safe use of the facility’s equipment can reduce the risk of such equipment-related injuries. Equipment should be used only as intended and properly maintained to ensure it is working well.

Errors and adverse events occur relatively frequently in the complex healthcare environment in which nurses work. According to www.healthmanagement.org, collaboration and mutual trusts among team members is critical to optimize care. Recognizing and reporting errors will help develop systems to prevent mistakes and improve performance. Medical transcription services are a practical strategy to accurate and timely EHR documentation and reduce stress on nursing staff, increase focus on patients, reduce the incidence of medical errors, and optimize care.

SOAP Notes in Psychiatry – Features and Tips for Improvement

21-November-2019 Rajeev Rajagopal Medical Transcription Company

SOAP Notes in Psychiatry

The SOAP (subjective, objective, assessment, and plan) note is one of the most important reports that medical transcription companies help physicians document. In mental health, writing clear and concise SOAP notes is essential to record the patient’s continuum of care. Providers use SOAP notes to monitor and document patient progress, record services, and communicate patient information to other professionals.

While there have been debates about the relevance of the SOAP notes in the EHR due to the increased complexity of medical care, this documentation method continues to be useful in the current context with appropriate EHR integration. Mental health transcription services are a practical option to maintain timely, effective and meaningful SOAP medical notes in the EHR.

Streamline your mental health documentation with our professional transcription services!

SOAP Note Structure in Mental Health

The elements in acronym SOAP are Subjective, Objective, Assessment and Plan. Here are the main aspects that need to be included in a SOAP note in behavioral health:

Subjective – Documentation under “Subjective”, the first heading of the SOAP note describes the patient’s personal views/feelings of a patient or comments of a person or persons close to them. In addition to the chief complaint and present symptoms, the physician should document medical and family health history and changes in functioning.

Objective – This section covers the objective data collection during the patient encounter such as vital signs, physical exam findings, laboratory test and imaging results, and other diagnostic information. It also includes recognition and review of the documentation of other clinicians. In the mental health assessment, the objective part of SOAP notes relates to how the body functions and assesses neurological functioning with the Mental Status Exam (www.icanotes.com).

While symptoms are documented in the Subjective section, signs should be noted in the Objective section. Symptoms are the patient’s description of the condition while signs are the objective evidence of the symptom that is observed. For example, if the patient reports feeling agitated, the signs may include racing pulse, sweaty palms, shaky hands and dry mouth. The patient’s current medications (including the medication name, dose, route, and how often) and allergies may be documented in either the Subjective or Objective sections.

Assessment: This section contains the physician’s impressions and interpretations based on the information documented in the Subjective and Objective sections. The aim of the assessment is to arrive at a diagnosis (problem). However, the initial visit may not include a diagnosis, especially if the condition is complex and needs more subjective and objective data to identify the problem. All possible diagnoses – differential diagnoses – should be listed in order of importance, from most to least likely, along with the decision-making in the diagnostic process. The Assessment should include only the most pertinent information.

Plan: The Plan brings the above three sections together to formulate the treatment plan and any additional treatment steps. It allows future providers to understand what needs to be done next. The Plan should include action to be taken for each diagnosis. ICA Notes lists the contents of the Plan as follows:

The treatment administered in each session and the rationale for it
The patient’s immediate response to the treatment
Date of next scheduled visit
Any instructions given to the patient
Goals and outcome measures for new problems/problems being re-assessed

If the patient has multiple concerns (such as depression and substance abuse) there should separate plans for each diagnosis.

An MDEdge Psychiatry article published 2019 April makes 6 recommendations for better organizing the P in a SOAP note in mental health care. According to the article the goal should be to organize the plan in a way that it is systematic and relevant across various psychiatric settings, such as outpatient, inpatient, emergency room, jail, pediatric, geriatric, addiction, and consultation-liaison. The author recommends a Plan format that has six categories: Safety concerns, collateral, medical, Nonpharmacologic interventions and assessments and nonpharmalogic interventions that would be useful, and time frame for disposition/follow-up, based on whether outpatient or inpatient.

According to the American Academy of Child and Adolescent Psychiatry, about one in five children have significant mental health challenges. One main challenge is ensuring consistency and continuity of care for those with mental health and substance abuse issues. There is also a shortage of providers to meet the needs of the population. While public awareness of mental health is growing, a common problem is the people who need mental health services often face difficulties in getting timely and effective treatment. Most individuals do not acknowledge that they have a mental illness and even if they recognize the problem, there is potential stigma associated with seeking mental health treatment.

Good documentation, including proper SOAP information, helps improve quality of care. As they deal with these challenges of managing patients, physicians can rely on a medical transcription service provider specialized in psychiatry transcription for documentation support.

Read our blog on Key Tips to Write Better Mental Health SOAP Notes

Trust our mental health transcription experts for comprehensive and secure transcripts.

Talk to our team at (800)-670-2809 and try our services for Free!

Get Started Now!