Optimize EHR Documentation with Medical Transcription

04-April-2016 Rajeev Rajagopal EHR Transcription

EHR Documentation One of the biggest criterions for successful adoption of Electronic Health Record (EHR) is integration of medical transcription. Electronic health records are implemented in healthcare units to help physicians improve care provision and co-ordination but it poses real challenges and makes the entire consultation process tedious for both patient and physician. This is because many physicians feel that they spend more time typing rather than listening to their patients. When physicians are forced to change their habit of dictating patient details and instead struggle with EHR templates to input complex patient information, they find a lot of valuable time lost. The need to enter data into the EHR will also extend the patient’s visit and reduce eye contact. This can cause distress in patients and also distract the physicians from processing the information and obstruct their workflow.

While physicians can continue dictating notes and use a speech recognition system to transcribe the notes, it would require a human editor to make complete sense of the notes transcribed by the software. Now there is another interesting solution put forward.

The physician can perform the consultation and a trained medical coordinator or a medical transcriptionist will perform data entry from a remote location, while securely listening to the entire physician-patient encounter.
The data entered will be displayed in real time on a large monitor or iPad in the consultation room.
The only thing the physician has to do is to review the data and authenticate. The medical coordinator will be in constant communication with the physician to correct any wrong details or uncertainties.

The medical coordinator can also perform other duties like calling nurse, accessing lab reports and make them available when necessary, inform the physician if a patient’s record is missing etc. This process will allow the physician to concentrate more on the interaction with patients and provide quality care to the patients.

It is best to appoint a medical transcriptionist as medical coordinator. This is because they are trained and have extensive knowledge about medical terminology and common clinical processes. This will reduce the chance of errors; moreover they require only minimum monitoring by physicians unlike staff that is untrained in listening to and transcribing physician notes.

Whatever may be the transcription requirements of a healthcare organization or entity, large volume or small volume, a reliable medical transcription company can provide customized solutions. They offer the service of staff that can function as medical transcriptionist, medical editor or medical coordinator, offering the best services to their clients. These services are the best alternative for healthcare providers wanting to focus on patient care, streamline medical documentation and enhance revenue.

Ensure Quality Medical Transcription with Good Dictation Practices

31-March-2016 MTS TEAM Medical Transcription

Dictating is an inseparable part of a physician’s functions. In fact, accuracy and timeliness in medical transcription depends on clear, error-free dictation by the healthcare provider. Even with electronic health records, medical transcription services have not lost its significance with industry experts recommending a blended approach.

According the Medscape Malpractice Report 2015, poor documentation of patient instructions and education was listed as one of the main reasons why specialists in general surgery get sued. Good dictation practices are important to avoid transcribing errors and ensure quality clinical documentation. Transcribing mistakes can have adverse consequences on patient care, result in legal issues, impact coding and billing, and ultimately affect practice revenue.

Dictation Challenges that Medical Transcriptionists Face

Physician workload and their tendency to multitask affect the quality of the dictation significantly. Some physicians dictate on their speakerphones while in a car and some in rooms with a lot or people talking, which badly affects clarity of the recording. One of the problems of poor dictators is lack of a consistent format. Patient demographic information is not entered and even if it is, the information is incomplete. Accents, background noise, and speech patterns all affect the quality of physician dictation.

Tips to Ensure Quality Dictation

The following steps can help physicians get the best outcome from their medical transcription company:

If you use a digital recorder, learn how to use it properly.
Speak clearly and in a conversational tone.
As far as possible, try to record the dictation in a quiet place.
Spell out unfamiliar medical words, terms and names of new drugs or treatments.
Have necessary documents and reports in place before starting the dictation.
Use punctuation at the beginning and end of paragraphs and sentences.
Provide adequate patient identification at the beginning of the dictation. Patient details such as full name and address, patient record number, date and time of the interaction, and subject matter should be clearly specified. Among other things, missing information in a record will delay billing and reimbursement.
Consistency can help while dictating similar reports. This will make the file easier to transcribe and lower the chances of errors.
Do not use slang or abbreviations unless they are commonly used in the medical field.
If you happen to make an error, delete it and rerecord the term or phrase.
Digits should be clearly specified for patient safety reasons. Incorrect dosages in the patient chart could be disastrous. For instance, the numbers 13 and 30 could be confused and it is best to spell out similar sounding numbers and homonyms for the sake of clarity.

Poor sound quality and dictation have an immediate impact on timeliness. Medical transcriptionists may have to spend several hours on a poorly dictated report. As dictation is not part of medical training, physicians need to review and hone their maybe dictation skills. Going by the above tips will promote timely and accurate medical transcription.

How Medical Transcription Has Evolved in the EHR Age – 6 Major Considerations

28-March-2016 Julie Clements EHR Transcription

With the advent of technology, the healthcare industry has undergone significant changes. However, medical transcription has remained a fundamental and necessary requirement in the healthcare sector. Technological changes have had a significant impact on how doctors’ notes are entered into the medical records, and on how transcriptionists are employed and work in a hospital or other healthcare facility. Verbal dictations have evolved into digital audio recordings and handwritten patient records have transformed into electronic health records. In keeping with this, medical transcription has also undergone changes in order to stay updated and relevant in the present age. Let us consider 6 major developments in the healthcare arena and how medical transcription has evolved to stay abreast with these innovative changes.

Digital recordings: Electronic recordings in lieu of dictations have made the job of medical transcriptionists easy. Digital recording allows transcriptionists to work from anywhere. Though there are challenges involved such as muffled recordings or ambiguous references, these are efficiently handled by the trained and experienced team at a medical transcription company. Trained in transcribing physician notes for various medical specialties, professional transcriptionists are knowledgeable regarding medical terminology, procedures and jargon commonly used by medical professionals. They can make sense of what is being said and ensure maximum accuracy with the support of the QA team.
Electronic health records: Electronic health record is the digital record of patient health information generated in a healthcare unit. It can be exchanged among and accessed by healthcare providers and patients. With electronic health records, no more file cabinets are required and it also reduces the need for storage space. To maximize the potential of the electronic health record, it is vital that the health documents are standardized. The transcriptionist in the EHR age should be trained in health terms, vocabulary, format and above all ensure that healthcare providers can easily read and understand the transcripts prepared.
Increased demand for error-free data: In this digital era, a medical transcription firm providing value-added services need to ensure that the transcribed records are highly accurate. QA is very significant now, which the company would provide with an experienced quality assurance team. They would identify and flag errors in patients’ records thereby ensuring patient safety and provider compliance.
Software for voice recognition: With voice recognition software, physicians can dictate the patient’s records. This helps the transcriptionist to review and edit the health record easily rather than create the record from scratch. With the introduction of voice recognition software, the transcriptionist’s role has changed to that of a medical editor.
High expectations: Digital advancements enable people to get information about everything quickly. Healthcare providers also like to have the information they need promptly. Cloud-based health records and other digital productivity tools that enhance efficiency help transcriptionists to provide speedy and excellent quality service.
The need for formal training: Earlier, doctors could hire anyone for transcribing medical notes but now with digitization and increased demand for accuracy and compliance, they need to ensure that the transcriptionist is well-trained and experienced. This is where professional EMR integrated medical transcription services become relevant. In this case, the transcriptionists would have undergone a formal training program that equips them with the necessary medical knowledge and skill to ensure accuracy and quality of the transcripts. They keep themselves updated on the new technological developments in the industry, and provide valuable service to their clients.

Accurate Medical Records Critical for Upholding Patient Safety and Physician Integrity

24-March-2016 Rajeev Rajagopal Medical Transcription

Medical transcription services help physicians to document patient care accurately and in a timely manner. Medical records help physicians to provide quality care by tracking the patient’s medical history and identifying issues or patterns that could help decide the treatment to be administered. Patient records can function as a powerful tool in the health care scenario only if they are complete and accurate, and it is up to the physician to ensure this.

Errors in medical records could negatively impact patient care with serious consequences. Failure to maintain accurate medical charts records would also pose a barrier to the physician’s defense in the event of malpractice litigation. When a legal case is filed, an independent medical consultant will review the relevant medical documentation to see if the physician had provided proper care or was negligent. The services of a reliable medical transcription company can prove invaluable in this context. Professional service providers have teams of trained and experienced medical transcriptionists that can ensure that patient charts, progress reports, doctors’ notes and more are accurately transcribed and delivered in quick turnaround time.

Here are some useful guidelines provided by the MIEC (Medical Insurance Exchange of California)Loss Prevention Department to help physicians maintain accurate and comprehensive medical records to support patient care and protect their own reputation.

Use an electronic medical record (EMR) that meets physician practice management and documentation needs. Computerized medical records should ensure good documentation.
Ensure that medical charts are well organized and neatly maintained and contain relevant documents and date such as progress notes,lab reports, correspondence, copies of hospital reports and other materials. Each page of the record should have the patient’s name/identifier.
Progress notes should begin with the reason for the patient’s office visit, with the chief complaint recorded in the patient’s own words
Allergies or lack of them, current medications and names of other treating physicians should be clearly charted and highlighted. The conditions and medications being managed by other treating physicians should be included.
Including an up-to-date problem list highlighting any serious medical conditions that the patient has would be useful to enhance communication among co-treating physicians.
All chart entries should be signed by the treating physicians and staff notes should indicate that the medical instructions given to the patient came from the doctor.
All prescription medications and renewals should be charted and all details of physical exam findings should be mentioned in the progress notes.
Phone calls and referral notes need to be documented.
Physicians need to document informed consent discussions
They should give evidence in the chart about patient education dispensed and also carefully document any failure on the patient’s part to follow medical advice.
Progress notes should include return visit advice as well as failed or cancelled appointments.

Partnering with an established HIPAA-compliant medical transcription company would go a long way in ensuring complete, accurate and secure medical records that fulfil legal and regulatory requirements and contribute to comprehensive and high quality patient care.

4 Main Reasons to Outsource Medical Transcription

21-March-2016 MTS TEAM Medical Transcription Outsourcing

Outsource Medical Transcription Medical transcription is a labor- and time-intensive activity that requires trained and experienced medical transcriptionists. It is very much relevant in this contemporary EHR era also because many physicians prefer to dictate their notes as before and have it transcribed. Medical transcription companies have risen to the occasion by making available EHR integrated transcription. Outsourcing medical transcription helps physicians and other healthcare professionals to do more with less time, money and resources. With budget restraints, tight deadlines, strict rules and regulations and huge volumes of data, healthcare personnel find it challenging to manage their daily tasks. Outsourcing is a great solution in this regard that would allow providers to focus on more important activities. Here are some other outsourcing benefits.

Cost- effective: One of the main advantages is that a reliable medical transcription company offers cost-effective transcription service that will prove highly advantageous in the long run. It also reduces maintenance cost, transcriptionists’ training cost, and the cost of buying transcription equipment.
Reduces storage space: By outsourcing you can eliminate the need for implementing transcription software and equipment. This will empty up a lot of space that can be put to other use.
Flexibility: In the medical field, many changes occur in quick succession and transcription providers can help you meet these rapidly changing conditions. The changes could be new treatment methods, report format changes, adding new specialties, changing voice recognition software and so on.
High quality and accurate medical records: Transcription service providers have experienced and trained transcriptionists who ensure high accuracy and clarity while transcribing physicians’ dictations. The performance of the transcriptionists is measured and penalty imposed on them for any mistakes. This ensures good quality, accurate transcription.

By hiring dependable medical transcription services, the problem of handling large volumes of medical records is taken off your shoulder. By outsourcing you free yourself of the burden and save a substantial amount of money. They also ensure that all necessary documentation is completed in a timely and efficient manner.

Patient-driven Education and Accurate Documentation to Ensure Exceptional Healthcare

17-March-2016 Julie Clements Medical Transcription

Patient-driven Education Endocrinology medical transcription is a valuable service for endocrinologists who diagnose and treat conditions such as diabetes and thyroid disorders. Accurate transcripts with details of the diagnoses and therapy provided have to be maintained to ensure proper care and follow-up treatment. Among the records maintained would be those pertaining to office visits, SOAP notes, follow-up visits, consultation notes, and evaluations. These transcripts would contain important details such as medical history of the patient, physical examination, diagnostic testing, impression and treatment plan. Endocrinologists treating diabetic patients would maintain records relating to Type 1, Type 2 and gestational diabetes. Many hospitals, individual physicians, physician practices and other providers obtain medical transcription services to ensure that all the health information of their patients are accurately recorded and made accessible any time.

Types 1 and 2 diabetes are chronic medical conditions that usually last a lifetime. The patient is given insulin as part of the treatment. Patients with Type 1 diabetes receive insulin injections and are advised dietary and exercise adherence. Patients with Type 2 diabetes are prescribed tablets, exercise and a special diet though sometimes this group may also receive injections. It is important to treat diabetes because if it is not controlled, it may lead to complications such as hypoglycaemia, ketoacidosis, and non-ketoic hypersosmolar coma. Other concerns include retinal damage, cardiovascular disease, nerve damage, poor wound healing, chronic kidney failure and gangrene on the feet.

Lifestyle counselling is an important part of diabetes treatment. When children are diagnosed with diabetes, their parents have to be given the proper counselling to ensure the wellbeing of the kids. An important question in this regard is how to provide the right recommendations and advice.

Visiting the hospital, consulting the doctor and forgetting half of what was told to us is common problem with many of us. This can happen whether you are a health-literate or whetherand whether you’re a parent dealing with your child’s acute sickness or chronic disorder. you are a parent faced with your child’s chronic disorder or acute sicknessand whether you’re a parent dealing with your child’s acute sickness or chronic disorder.and whether you’re a parent dealing with your child’s acute sickness or chronic disorder.. Research from the University of Pennsylvania, Texas Christian University and University of Texas at Arlington found that for parents who have children with acute sickness or a chronic disorder like Type 1 diabetes, the counselling and communication must be learner-driven and not instructor-driven. This is important for parents who have very low health literacy.

The findings of the research were published in the November issue of the Journal of Health Communication. Health literacy is the capacity to obtain, process and understand the basics of health information. Parents try to keep their children healthy, especially those who have chronic and complex ailments like diabetes Type 1. These parents work with healthcare providers and diabetes educators to provide better care.

The researchers selected 162 parents who had children with Type 1 diabetes and had consulted a diabetes educator at least once in the previous year. The participants completed a survey that looked at measures that included general clarity, explanation of conditions and care, and parents’ concern. A smaller group was interviewed about their perception and needs regarding diabetes education.

From the survey it was clear that each parent wanted to be taught at their own pace. The results of the survey were interesting but surprising to the researchers who found that both sets of parents were frustrated and dissatisfied with the kind of diabetes education they were receiving.

Generally healthcare providers use a lot of medical terms and speak very quickly. But with these patients, they believed that they had delivered the message at an average pace so that each parent could understand well, but this didn’t seem to be working. The findings of the research strongly suggest that healthcare providers should evaluate the healthcare literacy of each parent and then decide the communication methods required. This means that the level of counselling standard should be adjusted according to the healthcare literacy of each parent.

E- Learning tools could be provided to the parents so that they can watch, re-watch and understand various relevant medical aspects during their free time. The e-learning should have visuals and demonstrations that are completely patient-driven. Such measures can have a positive impact on the healthcare system and enable to provide patients better care.

Endocrinologists vested with the responsibility of patient education and lifestyle counselling can consider obtaining endocrinology transcription services to convert their dictated notes into professionally formatted medical reports. Moreover, practicing endocrinologists can utilize the toll free phone-in-dictation facility provided by a medical transcription company to dictate their patients’ medical details, which will be transcribed by medical transcriptionists. With the new EMR requirements, doctors can either make use of the EMR software provided by the transcription company and save on in-house operational costs or request the company to enter the details into their own office EMR through EMR integrated transcription service.

Proper Documentation a Critical Aspect in Chronic Pain Management

14-March-2016 Rajeev Rajagopal Pain Management Transcription

According to the Institute of Medicine of The National Academies, up to 100 million Americans suffer from chronic pain. Good documentation is crucial when treating chronic pain patients. The physician has to ensure accurate pain management transcription of the dictated patient records in order to set the framework for the evaluation of the treatment plan and subsequent actions. The lack of complete and clear documentation in patient medical records can have a negative impact on clinical preparedness as well as the revenue of the healthcare practice since documentation is the key to proper billing.

Chronic Pain Treatment – Key Points that Need to Be Documented

An article published in Baylor University Medical Center Proceedings (BUMC Proceedings) discusses the main points that need to be documented when providing care for chronic pain patients. They are:

Patients’ prior treatment history: This should include history and physical, progress notes, orders, procedure reports, consultation reports, discharge summary, other physician reports, anesthesia reports, lab reports, imaging reports and so on. Comprehensive documentation will raise the threshold at which consultation and referral for other treatment options are needed.
All aspects of the manner in which their pain affects the patient: Complete documentation of the effects of chronic pain on the patient will provide the physician with many ways to validate the benefit of the treatment provided for the patient’s chronic pain.
Why a medical management plan is reasonable.
Subsequently, how the medical management plan is helping the patient.

According to the author of the article, putting in extra time and effort in documenting these matters will make subsequent documentation easier. It will provide the physician with a baseline from which it is easy to evaluate and document how the patient is responding to therapy, whether the treatment plan is proving beneficial for the patient, and whether further consultation or referral is needed.

In the electronic health record (EHRs), documentation mainly involves checking appropriate boxes. While inadequate documentation pertaining to patients with other medical condition such as hypertension, diabetes, chronic obstructive pulmonary disease may not lead to medical board discipline, regulatory scrutiny of chronic pain patients treated with opioids is very common. The physician needs to meticulously document follow-up office visits, urine drug screens, phone calls, emails, and even communications with the patient’s family as well as maintain an up-to-date medication chart.

With these rigorous documentation requirements, physicians are increasingly relying on reliable medical transcription companies for timely, error-free pain management transcription. Professional service providers ensure an integrated approach that blends EHR and medical transcription service where physician dictation is transcribed, edited, reviewed and fed into EHR fields.

Oncology Imaging Tests and Their Documentation

10-March-2016 MTS TEAM Oncology Transcription

Oncology Imaging Tests Along with reports on biopsy, blood tests and Positron Emission Tomography (PET), oncology medical transcription also involves transcribing dictations related to several imaging tests including X-rays, CT scans, MRI and Ultrasound. Newer imaging modalities like magnetic resonance spectroscopic imaging (MRSI) also offer the potential to detect cancers in the prostate.

These imaging studies help oncologists to determine clinical stage and take initial treatment decisions such as the appropriateness of upfront surgery versus systemic therapy. Imaging studies are also used to monitor response to treatment including defining the events of tumor remission, recurrence, and progression.

A recent research from Thomas Jefferson University found that the imaging test developed by their team is much better at detecting prostate cancer than any other tests in use today such as biopsy or blood. This newly developed imaging test was reported to detect even more cancerous lesions than what pathologists found when they examined the prostate glands after they were removed. With more and more use of such imaging studies, reliable documentation of these reports is becoming crucial.

Oncologists and radiologists often communicate through various forms of clinical documentation such as paper or electronic radiology requisitions, and radiology reports summarizing the findings. With accurate documentation of imaging reports, patient care is also enhanced.

The oncologist reviews the radiology report and images to make diagnostic and treatment decisions. Imaging studies are sometimes dictated as operative reports or procedure notes, particularly if the procedure was performed in an operating room. Oncology reports include:

Clinical notes that include discrepancies with previous findings
A paper or electronic radiology requisition form that the oncologist used to order the study
Demographics that include name of the patient, type and date of examination
Impression (conclusion or diagnosis) that reports specific or differential diagnosis and any significant patient reaction
Clinical trial protocol that specifies the frequency with which imaging studies should be acquired
Medical chart that notes any action taken or initiated by a clinician or team member in response to a lab test result or imaging test report

Apart from diagnosis, treatments such as radiation therapy also need to be recorded in radiation oncology. While transcribing these imaging documents, the transcriptionist must be familiar with X-ray views, anatomical planes of the body, and other imaging test processes. Formatting of X-ray reports differ from one facility to another. While outsourcing their transcription tasks, oncologists, radiologists as well as radiation oncologists must make sure to choose a medical transcription company that provides services of transcriptionists experienced in transcribing for the oncology specialty.

Better Clinical Documentation with Medical Transcription

29-February-2016 Rajeev Rajagopal Medical Transcription

Clinical Documentation Medical transcription is the process of converting the dictations of healthcare professionals into a suitably formatted text record. It plays an important role in the medical documentation industry. However, with the advent of EHR or electronic health records, healthcare providers have the responsibility of filling up details in the patient’s EHR. This can cause a negative impact on the treatment provided and the way providers interact with their patients. Moreover, physicians may adopt short cut methods in order to save time. Improper or incomplete medical records demonstrate that the treatment was incomplete, reflect poor clinical care, leads to loss of reimbursement, and compromises on the safety of the patient. HIMSS EMR Adoption Model shows that 41.3% of healthcare providers have reached Stage 3 for the 3^rd quarter of 2012. Only 7.3% have reached Stage 6 that includes structured templates and physician documentation. Inappropriate documentation can also result in legal issues. To prevent such problems, it is better to employ medical transcriptionists who will add value to the clinical documentation workflow. Now, physicians can conveniently utilize EMR integrated medical transcription services.

Usefulness of Outsourced Medical Transcription

Enhances patient-physician interaction: By using medical transcription services, physicians can focus more on interacting with the patient. The physicians only have to dictate and the medical transcriptionist will listen carefully and transcribe accurately. Physicians will no longer have to concentrate on documenting the clinical notes and instead focus only on providing quality care to the patients.
Helps members of the patient care team: Medical transcriptionist can transcribe the physician’s notes quickly and make them available. This will help the healthcare staffs and other medical administrators to access, review and share the medical records without any delay. It also helps the physicians to understand and capture the information that is required in narrative form.
A more comfortable documentation option: Dictation and medical transcription easily fits into a physician’s workflow. It removes the burden of documenting medical records from physicians and enables them to focus on their core duties. A good transcriptionist provides insightful transcription that is accurate and reliable, which is most important to ensure appropriate care and follow-up for the patients.

A medical transcription company with a good track record in the industry offers several levels of quality control to make sure there are no errors or incorrect medical terms, ensures improved accuracy and cost-effective services. Sensitive to the varying requirements of different medical specialties, they also provide customized services.

How to Draft Effective Referral Letters

25-February-2016 MTS TEAM Medical Transcription

Draft Effective Referral Letters With medical transcription outsourcing, doctors and hospitals are now able to streamline their functioning better. Such EHR-compliant solutions can help physicians and specialists to focus more on rendering care, which does improve overall patient satisfaction.

Outsourcing is important in the healthcare field since doctors are highly specialized professionals, with many of the administrative and paperwork responsibilities sometimes overwhelming them. Transcribing paperwork and documentation is one of those tasks. And among the documents being outsourced to a medical transcription company are referral letters.

Mastering the Art of Referral Letters

If there is one area of work where doctors might need a bit of assistance, since it isn’t exactly their core task, it would be in drafting referral letters. These letters only need to convey the point, but crafting them is certainly an art form that takes practice to master.

Effective patient care relies a lot on prompt information exchange between doctors, and referral letters are integral to this communication. It’s how doctors exchange vital information. It does save time when the sender crafts the letter appropriately with the actual needs of the recipient in mind without making it too long with unnecessary repetition. That ensures much time is saved for the recipient doctor or specialist, which can be spent on imparting care. It also prevents patient dissatisfaction, which eventually leads to a lack of confidence in the doctor.

Referral Letters Fall Short of their Potential

It has been discovered that the potential of referral letters is easily underexploited, which does affect the speed and the quality of care. In spite of the extent of clinician time spent on writing or dictating referrals, the quality, usefulness and conciseness of the information contained in them is often questionable. The Medical Journal of Australia (MJA) reveals that in studies conducted on referral letters, specialists have reported dissatisfaction with their content and quality, with concerns such as absence of:

Adequate medical history
Explanation for referral
Test results
Clinical findings, and
Prior treatment details

Form letters have been used for enhancing the communication and information content of referrals from general practitioners to specialists and hospitals. These short form letters do contain a lot more relevant information, and an improvement in quality has been noted in referral letters as a result. However, MJA reveals that this has not led to an improvement in reply letters.

In Australia, general practitioners (GPs) have been found to prefer computer-generated, structured letters rather than dictated and unstructured ones. GPs also prefer computer-generated discharge documents. A structured letter contains a list of problems plus management proposals.

Basic Tips for Referrals

For doctors who must focus on patient care, here’s a brief guide that could help them craft better and more result-oriented referral letters:

A simple referral may require just a few lines to describe the issue and basically express why the patient is being referred to the concerned specialist, and why the particular procedure or treatment is required. Details such as the social circumstances that are relevant to rehabilitation of the patient may also need to be included.
Print-outs of medication, past medical history, previous diagnostic tests, etc would be required, if relevant to the condition dealt with. In long print-out reports, it is important to highlight important points to save time and keep up the concentration levels of the reader.

Referrals aren’t always this simple, though. There could be complicated referrals in which the initial diagnosis is unclear in the first place. Then it becomes difficult what to say. In such cases:

It is important that you state right at the outset what you require from the specialist.
Then you could go into the complicated medical history and examination.
Again, when presenting the history, make sure to highlight the key points only rather than embarking on unnecessarily detailed description.
It is also important to make the specialist aware of the importance of the problem being faced in functional terms.

Providing Crucial Details Succinctly

You also need to advise on the expectations of a patient of an appointment. Stress or anxiety in the patient regarding the health condition or the hospital visit must also be presented. These are factors that could help the specialist understand the patient’s problem better.

In the case of emergency referrals, it is better for them to be written or typed rather than dictated to a secretary. It is important to make them short and precise, and it is also essential to highlight important points regarding the patient’s medical and social history, since emergency referrals are usually read by the junior members of the hospital team.

Medical transcription outsourcing services also provide transcription of referral letters, which are part of the important documentation to be maintained by physicians. While a bit of effort and skill is required for crafting referrals, physicians at least need not be worried about getting them transcribed.