How Open Notes can help in Mental Health Therapy

29-July-2019 Julie Clements Psychiatry Transcription

Each year, about 1 in 5 adults in the U.S. (46.6 million) experiences mental illness, according to the National Alliance on Mental Illness (NAMI). Mental health transcription services help therapists to maintain electronic medical records to accurately reflect their patients’ clinical condition. Good record-keeping is crucial in psychiatry practices to promote better communication and care as well as continuity, consistency, and efficiency.

With national OpenNotes initiative that works to give patients easy access to their health care visit notes, providers need to ensure that EMRs contain accurate lists of medications, symptoms, health problems, etc. A new survey conducted as part of a study published in the Journal of Medical Internet Research found that patients had a positive experience with reading their notes in their EMR.

How Open Notes can help in Mental Health Therapy

Challenges facing Mental Health Treatment

Despite increased public awareness about mental health issues and the need for open communication to manage the condition, many people delay treatment. A report in Psychology Today reported on the challenges facing mental health treatment:

People find it difficult to accept they may have a mental illness and worry about the potential stigma associated with seeking mental health treatment.
Many people who need mental health services cannot access suitable treatment.
For those who get treatment, the type and quality of the therapy can vary quite widely. Studies show that the type of treatment would depend on many factors, such as individual choices and preferences, organizational values and resources, systems/policy level factors, etc.
There is lack of consensus about the type of mental treatment that a particular patient should receive.

OpenNotes can transform Health Care, say Studies

After the patient visit, the therapist or mental health provider summarizes the information from the visit in a note that becomes part of the patient’s medical record. The note usually contains a diagnosis, information patients share with the clinician, medication updates, the medical assessment, a treatment plan or next steps, and other pertinent information from the visit.Many practitioners rely on a psychiatry transcription service providerto ensure accurate and timely documentation.

Reporting on the recent survey, the American Medical Association (AMA) points out that shared notes are especially useful for involving patients in their own care and building trust among “vulnerable patients with a lower sense of control”. The study survey, which was conducted in 2017, included responses from 23,710 patients or their caregivers from Beth Israel Deaconess Medical Center (BIDMC), the University of Washington Medicine system and the Geisinger system.

About two-thirds of patients said they benefited from reading their notes
Only 3.3% said they were confused by their notes
Only 4.8% said reading their notes made them more worried

Therapists who implement the OpenNotes program share visit notes with patients, either online using secure patient portals, or on paper. The key benefits of shared notes include:

Improved communication
Improved safety
Reminds patients of their health plan
Patients can follow up on recommended procedures, tests or appointments, which can improve adherence
Better patient-doctor relationships
Helps patients be better prepared for physician-office visits – patients can review steps taken, any changes or new problems they have, and prepare questions to ask their therapist at the appointment

A 2013 study noted that by writing notes useful to both patients and themselves and then inviting patients to read these notes, clinicians can help patients address their mental health issues more actively and reduce the stigma they experience (www.opennotes.org). Patients tend to feel empowered when they realize their own abilities in reading notes, talking about them with their clinician, and putting them to constructive use.

Access to Visit Notes – Privacy Concerns

There are several things that physicians need to keep in mind while giving patient access to clinical notes. One key concern is privacy, according to the recently published study. The authors noted that almost 11.5% of clinicians and patients said they were “very concerned” about privacy, and less than half reported actively addressing the shared notes during visits. The AMA STEPS Forward™ module recommends the following measures to address this concern:

Having a process in place for patients to privately and securely grant access to their records and visit notes to another person of their choosing
Let patients know they may have the chance to decide which notes can be viewed
Tell patients that they can withdraw viewing privileges from a proxy or caregiver at any time

The module also notes that clinicians can “hide” certain notes from patients and discuss them in person later.

While patients have the right to access to their record, mental health providers must still satisfy documentation standards and professional requirements. Experienced US based medical transcription companies are well equipped to help them with this.

Study: EHRs may not reflect Accurate Ophthalmic Medication Information

25-July-2019 MTS TEAM Healthcare News

Many ophthalmologists rely on outsourced ophthalmology transcription services to ensure accurate and timely patient records. Electronic health records (EHRs) offer many benefits for ophthalmology practices and have evolved significantly to improve documentation, coding, billing, and security of patient data. However, a new study published in JAMA Ophthalmology found that medication lists created by EHRs may not capture up-to-date and accurate information on ophthalmic medications. The researchers found mismatches between the transcribed progress notes and the structured EHR-based medication list. The study noted that these findings can compromise patient safety and care.

Study: EHRsmay not reflect Accurate Ophthalmic Medication Information

Benefits of Electronic Patient Records in Ophthalmology

With an aging population and increase in chronic conditions, the demand for ophthalmology and optometry services is growing. Supported by medical transcription companies, ophthalmologists leverage EHRs to document patient encounters and simplify collaboration between patient’s coordinated care team. Once patient information is entered in the system, the data becomes available for various uses,including billing and audit purposes. Other benefits:

Diagnostic tests and reports from ophthalmic photography, angiography, visual fields, OCT and measurements for cataract surgery can be stored and displayed in the patient’s electronic medical record (EMR).
Inclusion of these test results in the patient’s EMR allows the practitioner to interpret and see these results from anywhere, anytime.
All the latest ICD and CPT codes are integrated in the system, so that clinicians can capture, submit and track charges electronically. This improves medical billing efficiency.
EHRs can increase compliance with mandated documentation standards.
Secure digital records allow patients to view and monitor their care, set-up their appointments, and get prompt answers to their questions.

While EHRs offer all these advantages, researchers found that they may not reflect the most accurate and up-to-dateophthalmic medication information. This raises concerns about patient safety and continuity of care since many patients use EHR-generated printed medication lists to keep track of their prescribed medications between clinic visits.

Study highlights Discrepancies in EHR Medication Lists

The team examined medication-related information contained in the EHRs of 53 patients at the University of Michigan Kellogg Eye Center. The patients had been treated for microbial keratitis, or corneal infection between July 2015 and August 2018. The researchers compared the following types of documentation:

The structured medication list in the EHR server
Medications written into the clinical progress notes and transcribed by the study team

The study found that:

Of the 247 medications identified, 32.1% differed between the progress notes and the formal EHR-based medication list.
About one-third of patients had at least 1 medication mismatch reported in their EHR.

These findings are especially relevant for corneal infection because the drugs and treatments change rapidly for this condition, with some medications requiring compounding.

Medication Mismatch increases Risk of Avoidable Medication Errors

In a typical office visit, the physician provides verbal medication instructions to the patient. At the same time, the clinician or a scribe transcribes the discussion into the unstructured or “free text” section of the patient’s EHR. The printed after-visit summary given to the patient will include an EHR-generated medication list.

However, in practice, data about medications (and other information) is captured in multiple formats in multiple locations. Mismatches between the clinician’s notes and the EHR medication list can result in avoidable medication errors for patients who rely on the automatically generated lists.

The study listed the reasons for medication discrepancy (www.beckershospitalreview.com) as:

Medications not prescribed through the EHR ordering system (43.9 percent)
Outside medications not recorded in the internal EHR medication list (40.4 percent), and
Medications that were prescribed through the EHR ordering system and in the formal list but not described in the clinical note (15.8 percent)

Cornea specialist Maria Woodward, M.S., M.D., assistant professor of ophthalmology and the study’s lead author noted that this level of inconsistency is a red flag.

“Patients who rely on the after-visit summary may be at risk for avoidable medication errors that may affect their healing or experience medication toxicity”, says Woodward.

The Solution

The researchers’ suggestions to improve accuracy of medication information for patients are as follows:

The post-visit summary should include instructions on how the medications should be used.
To ensure that error-free medication lists, physicians need to double-document. The same information must be entered in two separate places – the clinician’s note and the formal medication list.
Developing software solutions to ease the burden of EHR clinical documentation and make it easier to reconcile medication names and dosage.

In a busy clinical setting, physicians focus on communicating directly with the patient, clarifying the treatment plan, addressing patient concerns and answering their questions. In this scenario, medical transcription outsourcing is a good strategy to ensure comprehensive, accurate note-taking.

Impact of Nonverbal and Verbal Communication in Clinician-Patient Interactions

22-July-2019 Rajeev Rajagopal Medical Transcription

Listening skills are important in the medical field. Speed and accuracy are key attributes when it comes to medical transcription services. To understand the physician’s dictated notes and create timely, error-free medical records, medical transcriptionists need to have strong listening skills. Likewise, nonverbal communication has a significant impact on the clinician-patient encounter and has been attracting increasing attention in recent times.

Impact of Nonverbal and Verbal Communication in Clinician-Patient Interactions

The benefits of effective nonverbal and verbal physician-patient communication include:

Builds a restorative physician-patient relationship
Enhances patient autonomy
Promotes patient-centered care
Encourages patients to share vital information required for an accurate diagnosis of their condition
Gives physicians a better understanding of patients’ needs, which can potentially lead to better symptom reduction
Improves patient understanding and adherence to treatment plans
Reduces physicians’ work-related stress and burnout
Has positive effects on health care costs by reducing diagnostic tests, referrals, and length of hospital stay

Studies have found that nonverbal communication accounts for about 80% of essential communication between individuals. HealthLeaders recently reported on a doctoral study which provided evidence that nurses can improve the patient experience by honing their listening skills. Listening impacts the quality of the interactions between healthcare staff and patients, and this influences patients’ emotional functioning, quality of life, adherence to treatment, and ability to recall information. The author points out that active listening can influence HCAHPS scores and patient care compliance, and positively influence a healthcare organization’s financial wellbeing.

The study participants comprised 23 patients from 15 different health systems in Southern California after they were discharged from their inpatient stay. The researcher’s aim was to understand patients’ perspectives on:

nurse behaviors which indicate if listening has or hasn’t occurred
how their experience with nurses who listened or did not listen affected them during hospitalization and after discharge

Positive listening behaviors: Patients regarded the following as positive listening behaviors:

Making a connection: The study found that certain verbal nurse behaviors made patients feel that a connection had been made. These verbal cues include asking questions and personalizing care, encouraging the patient to share information, directly addressing the patient, and talking to the patient before performing a care task. Making eye contact, body language (especially sitting), and catering to individual patient care preferences were nonverbal behaviors that supported making the connection.
Reassuring the patient: Patients reported verbal behaviors that put them at ease as: narrating care, anticipating questions, providing reassurance, including family in discussions, and not complaining about job tasks. Nonverbal behaviors that reassured them included follow-through, empathy, not rushing to get out of the room, and therapeutic touch.
Ensuring safe and effective care: Patients felt they received quality care when nurses displayed positive verbal behavior such as answering their questions, repeating back what the patient said, passed along information, and asked if interventions worked. Positive nonverbal behaviors that patients considered as improving their safety included nurses assisting when needed, noticing patients’ body language, believing what the patient says, taking notes, taking direction from the patient, and taking nothing for granted.

Detrimental listening behaviors: Patients identified certain nurse verbal and nonverbal behaviors as making them feel they were not being listened to:

Arrogance – Negative verbal behaviors include arrogant actions and words, while nonverbal arrogant behaviors include not believing the patient and dismissing patient concerns.
Misuse of power – This includes discounting or making light of patient concerns, arguing with the patient, rejection of patient input, and not clarifying orders.
Incivility/Insensitivity – This includes fabricating excuses, a gruff tone or attitude, and stopping patients from talking. Patients saw lack of eye contact, eye rolling, acting put out, and focusing elsewhere as negative nonverbal behaviors.

While active listening in the healthcare setting is increasing in significance, it is more complex than it sounds. Nurses need to develop soft skills which will enhance teamwork and collaboration and lead to improved patient outcomes. The SAGE & THYME model can serve as a guide for listening and responding to patients’ concerns (www.nursingtimes.net). Recommendations include:

Listening fully without interrupting
Holding back with any advice until approaching the end of the conversation
Asking the patient what support they have
Asking patients what they think would help

A study published in BMC Med Educ in 2018 identified eye contact, posture, tone of voice, head nods, gesture, and postural position as the important non-verbal signs by a physician which influence a patient’s disclosure of history details in a consultation. Since verbal and non-verbal aspects of communication have an important impact on the physician-patient-encounter, the study recommends that undergraduate medical students receive explicit training on verbal and non-verbal aspects of communication.

Researchers have found that physicians spend more time working on their EHR than in face-to-face time with patients during clinic visit. EHR data entry has led to loss of eye contact, reducing the frequency of questions about psychosocial aspects in a patient’s medical history, a reduced response to emotional aspects provided by the patients, and to a reduced disclosure of history details by the patients (BMC Med Educ).

Reliable medical transcription outsourcing companies providing EHR-integrated documentation solutions can minimize such issues and improve physician-patient verbal and non-verbal communication during the office visit.

Six Key Tips for a Successful Doctor Appointment

18-July-2019 Julie Clements Medical Transcription

This is a continuation to the blog “Is There a Right Time to Visit Your Doctor?”

So, you have chosen a doctor and made an appointment. May be you have waited weeks or months for this appointment and so it’s crucial to make the most of this consultation time. Often, patients will get only a modest amount of time with the doctor. Medical transcription services that are EHR-integrated are of great assistance for busy doctors to save their time for quality patient care. Whether you are starting with a new doctor or even continuing with the doctor you’ve been seeing for years, prepare a basic plan to make the most of your appointment. The following tips will make it easier for you and your doctor to cover everything you need to talk about.
Six Key Tips for a Successful Doctor Appointment

Consider these tips for a more successful and stress-free doctor visit.

Prioritize your concerns and make a list
You may not remember everything you have to ask. So try to make a list of all your concerns. Preparing and prioritizing key questions that you should ask can help you feel more confident when talking with your doctor. Also, you will get the answers and info for all your concerns.You can even hand the notes to your nurse or doctor, providing them time to prepare the answers. A recent WebMDarticle discussed studies that proved that patients who filled out a detailed checklist before an office visit asked more questions during their doctor visit and got more satisfaction from the visit.

Record instructions or note them if you can’t remember
If you think you can’t remember everything that a doctor says during consultation, record them via smartphone with the doctor’s permission. This audio can be replayed for better understanding of the instructions and information provided. If recording is not allowed, take notes of the key points the doctor says during the visit.

Get all your medications and records
If you are a new patient, share your medical history and discuss your illnesses, operations, and medical conditions. Make a list of all the medications you take, as it will be difficult to remember the exact names and dosages of your medications when your doctor asks. Along with prescribed medications, make sure to include all supplements you take such as over-the-counter sleep aids, and other pain medications. Remember to bring results of medical tests – blood tests, X-rays or scans recommended by the doctor.

Note your symptoms
While meeting your regular doctor, if there’s a new symptom that you need to bring to your doctor’s attention, make sure to take a symptom diary with you which should include all the details like – what does the symptom feel like, when does it occur, how long does it last and more. Such a symptom journal can help you and your doctor to spot patterns and identify triggers for your symptoms, leading to more effective medical treatment.

Provide time for doctor’s EHR documentation
While large practices rely on medical transcription outsourcing companies to get their documentation tasks done, in small practices doctors have to feed the consultation details into the electronic medical records themselves. So provide time for doctors to complete their documentation as well.

Bring a family member or close friend with you
It is best to let your family member or friend accompany you to the doctor. Make sure they know the purpose of the visit so that they can remind you what you planned to discuss with the doctor, in case you forget any key points. They may also help take notes for you and can later remind you of what the doctor said. They can also help you make important decisions.

Check your insurance coverage also before you meet the doctor. Make sure to double check your insurance coverage. Also, confirm that your doctor accepts your health insurance before your appointment. Doctors can also add value to their time with patients by following certain tips such as using better verbal communication techniques than non-verbal and using open-ended questions.

Is There a Right Time to Visit Your Doctor?

15-July-2019 MTS TEAM Medical Transcription

Yes, there is. Workload is more for healthcare providers, mainly in primary care. These primary care doctors often spend 11 to 18 hours a day providing preventive and chronic care. AMA Insurance has reported that most physicians work between 40 and 60 hours per week and nearly one-quarter of physicians work between 61 and 80 hours per week. For every hour physicians spend with patients, they have to spend one to two hours updating the electronic health record. EHR documentation is another time-consuming task that physicians should focus on along with providing quality patient care. Outsourcing medical transcription can reduce the documentation workload to a great extent for physicians. A large proportion of medical errors are caused by physicians’ excessive workloads.

Is There a Right Time to Visit Your Doctor?

Physicians Suffer Decision fatigue, Finds JAMA Study

One important consequence of excessive workload is decision fatigue, which refers to the decline in decision quality due to an increased number of patients and treatment decisions. With excessive workloads, physicians will be forced to make more medical decisions.

According to a recent JAMA study, doctors ordered fewer breast and colon cancer screenings for patients later in the day, compared to first thing in the morning. This study was approved by the University of Pennsylvania researchers. It has been highlighted that

patients seen earlier in the day were more likely to have their doctors order cancer screening tests
ordering rates were highest for patients with appointments around 8 a.m.
but, by the end of the afternoon, the rates were 10 percent to 15 percent lower

Clinician ordering of cancer screening tests significantly decreased as the clinic day progressed. Decision fatigue is reported to be the key reason for this decreased rate of ordering tests. The researchers also acknowledged that the decline could also stem from doctors running behind on their appointments. As each shift progresses, clinicians may fall behind schedule, leading to shorter interactions with the patient at the end of the morning and afternoon shifts.

The first of its kind, this study also demonstrates that primary care clinic appointment time is associated with both ordering and completion of screening for breast and colorectal cancer.

The University of Pennsylvania researchers in their study has discussed an example that if at 8 a.m., 64% of women eligible for breast cancer screening left their appointments with an order for a mammogram, this declined to 48% by 5 p.m. A 2014 report highlights that as the day moves on doctors are increasingly more likely to prescribe antibiotics even when they are not indicated. The number of prescriptions also increased with time.

Physicians devote more time on EHR tasks

Several reports highlight the fact that electronic health records (EHRs) is a leading driver of physician burnout as doctors spend more than half of their workdays on the keyboard. A 2016 report published in Annals of Internal Medicine provides details about how physician time is allocated in ambulatory care. This study based on observation of 57 U.S. physicians in family medicine, internal medicine, cardiology and orthopedics for 430 hours points out that during the office day physicians spent

0% of their total time on direct clinical face time with patients
2% of their time on EHR and desk work

While in the examination room with patients, physicians spent

9% of the time on direct clinical face time and
0% on EHR and desk work

The study concluded that for every hour physicians provide direct clinical face time to patients, nearly 2 additional hours are spent on EHR and desk work in the office. Even outside office hours, they spend another 1 to 2 hours of personal time doing additional computer and other clerical work.

It is critical for physicians to find some innovative ways to stop spending too much time on EHR. Consider choosing a professional medical transcription services company that can provide EHR-integrated services.

In our next blog, we’ll discuss useful tips for a successful doctor appointment.

Why do Patients Keep Returning to the Emergency Department? [Infographic]

11-July-2019 Rajeev Rajagopal Infographics

Emergency departments (EDs) function as a focal point for care and care transitions. Medical transcription companies help emergency physicians with their documentation tasks. A 2018 article by the American College of Emergency Physicians (ACEP) noted that for over 20 years, “emergency physicians have been faced with hospital programs that report ED return visits, usually in a 72-hour window.”

Why do Patients Keep Returning to the Emergency Department?

Common Emergency Room Errors and Ways to Avoid Them

08-July-2019 Julie Clements Emergency Room Transcription

Each day, thousands of patients seek care in emergency departments (EDs) across the country. Many hospitals outsource medical transcription to ensure accurate, fast and reliable documentation so that ER physicians can focus on care. Law requires hospitals to guarantee a certain level of care for patients who come to the Emergency Room. Physicians can be held liable for any harm that comes to a patient if the ER treatment that was provided fell short of the appropriate standards of care. In a malpractice lawsuit, physicians need to prove that proper care was provided. Also, with the rise in consumerism in healthcare and payers now linking reimbursement to quality, hospitals need to provide a first-rate experience to maximize revenue. In addition to recognizing patient rights, Emergency Rooms need to assess their capabilities to follow standards of care and avoid common mistakes.

Common Emergency Room Errors and Ways to Avoid Them

Emergency Room Errors – Types and Causes

A study by the physician-owned medical malpractice insurer Doctors Company that covered 332 Emergency Room visit related claims between 2007 and 2013 revealed that the four most common errors as:

Failure to diagnose – 57 percent of cases
Failure to properly manage a patient’s care – 13 percent
Failure to properly execute a patient’s care – 5 percent
Failure to order medication for a patient

The researchers identified the reasons for these errors as:

Not conducting a thorough review of the patient’s medical chart, leading to failing to order a test to diagnose a patient or discharging the patient prematurely
Communication problems among physicians and also between physician and patient
Poor documentation
Inadequate staffing

More recent studies have also pointed to human error as the cause of ER mistakes. A study published in BMC Emergency Medicine in 2017 also found that most emergency department mistakes that compromised patient safety result from human error. According to a study published in De Gruyter’s Journal Diagnosis in 2018, about 45 percent of medical errors in the emergency room are due to problems with information processing. The researchers noted that it is a cognitive limitation and not related to technology.

Measures to Avoid Preventable ED Errors

Between 210,000 and over 400,000 premature deaths per year (575-1,095 deaths per day) are associated with harm that is preventable in hospitals, according to a study published in Journal of Patient Safety in 2013.

Avoid cognitive biases: There are five significant cognitive biases that can cause preventable errors: availability bias, anchoring bias, framing bias, confirmation bias, and premature closure. Emergency Room physicians can avoid these errors by:

Not basing a diagnosis on previous patient experiences with similar symptoms
Avoid making decisions based on the first piece of information received
Avoid accepting someone else’s diagnostic or personal biases
Check past medical history and risk factors for serious disease or poor outcome
Check vital signs and nurses’ emergency notes
Avoid premature closure if the diagnosis is not certain – keep the patient informed about the uncertainty, arrange for appropriate follow-up, and provide specific written precautions

Recognize patient rights: Physicians need to adhere to the Emergency Medical Treatment and Labor Act (EMTALA) by guaranteeing the stipulated level of care for Emergency Room patients. According to WebMD, this includes:

Offering patients a timely and appropriate medical screening exam
Stabilizing patients with emergency medical conditions
Maintaining proper and centralized records on ER patients and their care
Having a list of on-call physicians who provide emergency treatment
Accepting patients from other hospitals if the receiving ED has the facilities to provide the care they need
Reporting improperly transferred patients within 72 hours

Ensure emergency preparedness: Timing is crucial in a medical emergency. A survey by health site HealthGrove found that in many states, patients face a painfully long wait before they are seen by a physician or properly diagnosed (www. com). Long emergency wait times can exacerbate the problem. ERs and their physicians need to be prepared to handle themselves in a crisis, from man made calamities to natural disasters. They should:

Have the staff and resources necessary to assess all patients presenting to the ED. They should do a monthly stock check to make sure all drugs and supplies are available and up to date.
Have a emergency preparedness plan, clearly indicate who is responsible for implementing it, and ensure the staff is educated about the policies
Conduct mock drills and make sure that each staff member is flexible enough to step into a different role
Have proper communication strategies in place to contact staff as well as local, state, and federal emergency response personnel
Keep patients informed about their emergency care options

Improve the discharge process: Hasty or poor ED discharge can have significant clinical implications for patients, including unfinished treatments and progression of illness. EDs need to follow rules and ensure that meet patients discharge criteria when they are allowed to return home. According to the Agency for Healthcare Research and Quality (AHRQ), the characteristics of a high-quality discharge are:

Informs and educates patients on their diagnosis, prognosis, treatment plan, and expected course of illness, including treatments, tests, procedures
Supports patients in getting post-ED discharge care, including medications, home care of injuries, use of medical devices/equipment, and further diagnostic testing and health care evaluation
Coordinates ED care within the context of other health care providers, social services, etc.

Outsource Medical Transcription for High-quality Medical Record Keeping

Maintaining high quality patient medical records in the ED can promote improved patient care, according to the American College of Emergency Physicians (ACEP). An experienced medical transcription services company can help ER physicians maintain proper and legible documentation of the relevant aspects of the patient encounter including laboratory, radiologic, and other testing results. Good documentation can

Help prevent medical errors
Improve efficiency in the patient encounter
Enhance communication with other providers
Support coordination of follow-up care
Ensure identification of who entered data into the record
Assist with discharge instruction communication

Reliable outsourcing companies can provide HIPAA compliant medical transcription to ensure that ED medical records comply with applicable state and federal patient safety and confidentiality regulations.

Avoid Errors and Delays in Dictating Operative Reports

04-July-2019 MTS TEAM Medical Transcription

An operative report is dictated by the surgeon immediately after the procedure, detailing who did what to whom using what materials and methods. Operation reports also include dictations that surgeons or their assistants complete after operative procedures. Typically there is a brief written operative note and a more detailed operative report that is dictated by the attending surgeon in the chart. Medical transcription service providers can convert these dictated records into accurate transcripts.
Avoid Errors and Delays in Dictating Operative Reports
The dictated operative note is an integral component of patients’ medical records. Good surgical practice emphasizes the need for clear operative notes for every operative procedure done. Any error in dictation made by the surgeon can lead to errors in transcripts and thus in EHRs. Hospital payments are also facilitated by accurate coding that is ascertained from patient notes including the operation note.

A clear dictation should describe the operative indications and findings and detail the steps of the procedure performed. Though dictating operative notes seems to be straightforward, it may happen that surgeons fail to include certain crucial information.

What Do Operative Reports Include?

Immediately after surgery, a record of the operation should be made including the following details.

The names of the operating surgeon(s), assistant and theater anesthetist, the name of the consultant responsible
The diagnosis made and the procedure performed
Description of the findings
Details of tissue removed, altered or added
Details of serial numbers of prosthetics used
Details of sutures used
An accurate description of any difficulties or complications encountered and how these were overcome
Immediate post-operative instructions
The surgeon’s signature

The record should also contain information relating to anesthesia. Follow-up notes should be sufficiently detailed, which allows other doctors to assess the care of the patient at any time.

Surgeons Cannot Delay Operative Notes Dictation

If an operation is conducted, then the surgeon is responsible for dictating the operative report of the patient, describing in brief the details of the surgery. This report should be entered in the medical report immediately after the procedure.

If there is any delay in entering the reports, then an operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for anyone required to attend to the patient. Surgeons should make sure that such an operative progress note contains at least minimum comparable operative report information such as the name of the primary surgeon and assistants, procedures performed, estimated blood loss, specimens removed, and post operative diagnosis.

In case the assistant surgeon is dictating the op note to bill for the surgery as primary surgeon, he/she must at least sign the operative report, attesting that the information in the report is accurate. Without this confirmation, things may lead to potential malpractice if something goes wrong.

Also, if the surgeon accompanies the patient from the operating room to the next unit or area of care, the operative note or progress note can be dictated in that unit or area of care.

Within the operating room, surgical reporting best practices are key to reducing post-operative complications and preventing operative report errors. Most general surgery residents (92%) report that they use at least one method to improve their dictations. Surgeons can improve their dictating skills by considering these tips –

Dictate soon after the procedure, as the information will be fresh in your mind
Speak at a reasonable speed. Volume issues usually involve a dictator who whispers, possibly because of confidentiality concerns.
Choose a silent, quiet area. Always state your name and the name of the patient you are documenting care for.
Organize reports before dictating. With unorganized reports, you are likely to leave something out, especially if they are interrupted.

A poorly dictated report requires greater attention and more time from transcriptionists, which increases the turnaround time as well. Consider outsourcing medical transcription tasks to an experienced company to avoid any documentation quality issues.

An Ambient Listening System in the Exam Room – New Tech to Support EHR Documentation

01-July-2019 Rajeev Rajagopal Medical Transcription Outsourcing

One of the most challenging tasks for physicians is typing patient information into the electronic health record (EHR) during and after the office visit. US based medical transcription services ensure dedicated EHR-integrated clinical documentation, including editing of speech recognition-generated documents. At the same time, companies are in the race to develop innovative voice-enabled products and services to make EHRs easier to use and minimize the documentation burden for clinicians. The latest advancement in the field is an ambient listening system in the exam room.

An Ambient Listening System in the Exam Room - New Tech to Support EHR Documentation

Instantaneous EMR-integrated Transcripts of Physician-Patient Dialogue

Developed by speech recognition software maker Nuance, the Ambient Clinical Intelligence (ACI) solution is a tailor-made device that can be wired into the walls of the exam room. It combines ambient detection tools with Nuance’s Dragon Medical virtual assistant to transcribe the physician-patient conversation and upload key portions of it into the EMR.

This artificially intelligent software product is a rectangular box equipped with 16 microphones and a motion-detection camera. Mounted on the wall of an exam room, the system comes with the following capabilities:

Can record patient encounters and automatically load key data into matching fields within the EMR
Can capture and distinguish speech from up to eight persons in the room
Comes with as a computer vision sensor that can track speakers as they move and attribute speech to the right person
Convert layperson terms into their clinical language, promoting natural patient-physician conversation, while capturing details to support coding and clinical history
Allow for real-time documentation of patient visits, without the computer encroaching on the physician-patient relationship

The goal of the new technology, which is also HIPAA-compliant, is to address physician burnout and create meaningful, personalized patient experiences. Performing EHR data entry during the office visit leaves physicians frustrated as they are not able to focus on their patients. In a 2018 Stanford Medicine poll, physicians consistently ranked electronic health record as the top reason for the breakdown of the physician-patient relationship.

Similar to medical transcription services, ambient technology allows providers to avoid burdensome EHR data entry. The system is still in validation process, and if successful, would be a significant advancement in voice technology in healthcare.

Speech Recognition Technology in Medical Record-keeping – Key Challenges

Stat News points out that one key concern about ambient technology is whether patients will be at ease having a third-party company with camera and microphone present during their conversation with their physician.

Another major challenge is accuracy in documentation. Speech recognition (SR) helps with clinical documentation process in two ways: back-end and front-end. In back-end documentation, physician dictations are captured and converted to text by voice technology. This text is then edited by a medical transcription service provider and returned to the physician for review. The second type is front-end speech recognition where the clinicians dictate directly into free-text fields of the EHR and review and edit the transcription themselves. Front-end systems tend to increase the physician’s administrative burden instead of reducing it.

A recent study revealed that in clinical documentation created using speech recognition technology seven in every 100 words contained errors. Moreover, 1 in 250 words contained clinically significant errors. One error that the researchers discovered was a reference to a patient having a “grown mass” instead of a “groin mass”.

“Although adoption of SR technology is intended to ease some of the burden of documentation, that even readily apparent pieces of information at times remain uncorrected raises concerns about whether physicians have sufficient time and resources to review their dictated notes, even to a superficial degree,” wrote researchers (www. ehrintelligence.com).

Documentation errors that affect clinically relevant information put patient safety at risk. Though nearly all the errors were identified by follow-up review and editing, the researchers stressed the need for careful supervision to prevent errors in the final version of physician notes.

Speech recognition technologies are being increasingly recognized for their ability to help physicians manage the care of their complex patients. Patients with complicated conditions would have a complicated story to tell and physicians would find it difficult to type out quickly, according to a report from the American Medical Association.

All these challenges indicate that, even as technology advances, medical transcription outsourcing companies continue to have an important role in helping physicians maintain accurate, timely and clear medical records.

Electronic Consultations Expedite Care in Allergy and Immunology, finds Study

27-June-2019 Julie Clements Medical Transcription Company

The effective use of electronic health records (EHRs) can improve the quality of health care and patient safety. Supported by medical transcription companies, providers leverage EHRs to maintain better documentation and file organization. EHRs also help patients with adherence to medication regimens and scheduled appointments while assisting physicians in tracking their treatment protocols (IOM, 2010). Digitizing patient records has also facilitated electronic consultations or “e-consults”-asynchronous, electronic clinician-to-clinician consultations based on data in the EHR. A recent study by researchers at Massachusetts General Hospital (MGH) found that e-consults can streamline and expedite care in allergy and immunology by significantly reducing wait times and need for specialist visits. The study was published online in the Journal of Allergy and Clinical Immunology: In Practice.

Electronic Consultations Expedite Care in Allergy and Immunology, finds Study

According to statistics from the American Academy of Allergy, Asthma & Immunology and the National Institute of Allergy and Infectious Disease, allergic problems in the United States are the sixth-leading common cause of chronic disease. Allergies and autoimmune disorders are complex conditions. They include allergic rhinitis, angioedema, asthma, atopic dermatitis (eczema), autoimmune (e.g., lupus, multiple sclerosis and rheumatoid arthritis), bronchitis, celiac disease, contact dermatitis, chronic cough, food allergy and sensitivity, hives, and immunodeficiency diseases. When diagnosing and treating these conditions, the allergy and immunology team often has to work with other experts to ensure that patients benefit from specialist care.

The researchers looked at data regarding allergy/immunology e-consults provided under the MGH program from August 2016 through July 2018, as well as in-person consults beginning in August 2014. As of January 2019, the MGH e-consult program involves 47 specialty areas, and almost 10,000 e-consults were provided during 2018. Approximately 300 e-consults completed during the study period. Two-thirds of e-consults related to patients with histories of potentially allergic reactions to drugs like penicillin, many in conjunction with a program to evaluate pregnant patients with a history of penicillin allergy. Immunology e-consults could result from patient or provider concerns about frequent infections or abnormal antibody levels.

The study found that e-consults in allergy and immunology can simplify the process of providing proper care, often reducing the need for in-person specialist visits and the time needed to access specialist guidance. The findings are as follows:

About 60 percent of the 300 e-consults led to recommendations for in-person specialty visits, while 27 percent provided only advice and education to the referring practitioner.
When the e-consult led to a recommendation for an in-person specialty visit, information from the e-consult improved the productivity of visits by allowing the allergist to be better prepared.
The educational information that e-consults provided benefited both referring physicians and the patients, often providing reassurance on the appropriateness of a treatment plan.
Before setting up the e-consult program, the average wait time for an in-person allergist visit was 22.5 days. After the program began, the wait time reduced to 21.0 days.
Allergists completed e-consults in an average of 11 minutes, and the average turnaround time for the referring provider to receive allergy specialist guidance was less than 24 hours.

For many patients, e-consults avert the need for an in-person visit entirely; and even when an in-person consult is required, the initial e-consult provides valuable information – including additional patient history, previous diagnostic testing and treatment trials – that can make the in-person consult more productive and valuable for the allergist, the referring provider, and the patient.

Earlier studies have also reported that e-consults offer a potential solution to the challenge of enhancing access to specialty care. They offer the primary care physician (PCP) and the specialist a “rapid, direct, and documented communication pathway for consultation”, according to a study published in the Journal of Telemedicine and Telecare in 2015.

These studies show that e-consults are:

Offer flexibility and are a practical option in a variety of settings
Are very useful to PCPs by allowing them quickly to determine the best course of action with the guidance of a specialist
Improve timeliness of specialty consults
May help avoid the need for a face-to-face visit between the specialist and the patient
Frees up specialists’ office time to prioritize patients who need more complex care
Promote cost-effective and convenient care for patients
Enhance access to and coordination of specialty care across the healthcare system

Medical transcription services have improved the integrity of electronic medical records (EMRs), including record retrieval and management, and other processes. EMRs come with condition- and specialty-specific templates that prompt PCPs to document their expectations for care and determine the next course of action. Specialists who have opted to be in an e-consult program can write an effective e-consult response. This would ensure that the PCP has a record of specific instructions from a specialist (www.news.aamc.org).

However, a key limitation to more widespread use of e-consults is the reliance on EMR systems that may not be shared between specialists and referring physicians, according to Neelam Phadke, the first author of the MGH study.

How Open Notes can help in Mental Health Therapy

Study: EHRs may not reflect Accurate Ophthalmic Medication Information

Impact of Nonverbal and Verbal Communication in Clinician-Patient Interactions

Six Key Tips for a Successful Doctor Appointment

Is There a Right Time to Visit Your Doctor?

Why do Patients Keep Returning to the Emergency Department? [Infographic]

Common Emergency Room Errors and Ways to Avoid Them

Avoid Errors and Delays in Dictating Operative Reports

An Ambient Listening System in the Exam Room – New Tech to Support EHR Documentation

Electronic Consultations Expedite Care in Allergy and Immunology, finds Study

KEY FEATURES

RECENT BLOGS

Categories

Quick Contact