Tag Archives: Medical Transcription

Why EMR is Rated Beneficial for Physicians and Patients

Electronic medical records (EMR) have many benefits and if implemented efficiently can improve patient care and co-ordination among multiple caregivers. An electronic medical record is a digital version of a paper-based medical record and can be more easily managed. This … Continue reading

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Documenting History of Present Illness (HPI) Report in Ophthalmology Care

Obtaining an accurate history is the critical first step in determining the etiology of a patient coming with eye problems. Most of the time, you will be able to make a diagnosis based on the history alone. However, the value … Continue reading

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Importance of Incorporating SOGI Information within EHR

Expanding Electronic Health Records (EHRs) data collection to include sexual orientation and gender identity (SOGI) information is critical to eliminate the invisibility of LGBT (lesbian, gay, bisexual and transgender) people in the healthcare system. The Institute of Medicine (IOM) has … Continue reading

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How Death Summary is Different from Discharge Summary

Discharge summary is among the four types of reports that comprise the core of medical transcription work and is required whenever a patient is discharged from the hospital. This report is critical for further consultation and promoting patient safety while … Continue reading

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Transcribing Chart Notes in SOAP Format

Chart notes are dictated in various formats such as a History and Physical Examination (H&P) report with similar headings and less depth, as a single paragraph with few sentences, or using SOAP format. Most physicians rely on medical transcription services … Continue reading

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Reduce Complications with Accurate Transcripts of Cataract Surgery Reports

Even though the risk with cataract surgery is low, it does involve the risk of partial or total vision loss if there are complications associated with the surgery. It is estimated that less than 5 out of 100 people experience complications from this surgery that can threaten their sight or demand further surgery. Continue reading

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Effective Ebola Screening – Improving Clinical Decision Support with EMR Transcription

In order to enhance clinical decision support (CDS) tools within electronic medical records or EMR and ensure effective Ebola screening, representatives from the Centers for Disease Control (CDC) and the Office of the National Coordinator for Health IT (ONC) co-hosted … Continue reading

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Treating Infectious Diseases – Accurate Documentation Vital

Medical transcription of doctors’ recorded observations and treatment details is of great significance from the point of view of appropriate diagnosis and treatment. The transcripts have to be accurate, and there is no room at all for error. Continue reading

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Blows to the Head May Cause Brain White Matter Changes Even Without Concussion

Researchers have found that repeated blows to the heads of athletes may be associated with changes in brain white matter, and may also be linked to reduced cognition even if those impacts do not cause concussion. A study on athletes involved in contact sports vs. athletes participating in noncontact sports over a season revealed a small increase in diffusivity in the white matter. Continue reading

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Infectious Diseases Still a Threat to U.S. Public Health

A recent report published by the Centers for Disease Control and Prevention (CDC) reveals that infectious diseases (ID) still remain a threat to U.S. public health despite the control measures taken. Several measures were taken by the CDC as a … Continue reading

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