Documenting vitals and patient history during pre-op anesthesia is time consuming while recording vitals in the post-anesthesia care unit (PACU) will take away a significant portion of time dedicated for patient care. Electronic anesthesia documentation is considered a fast and … Continue reading
Read MoreElectronic health records (EHRs) are supposed to enhance the clinical outcomes with faster data input, exchange and retrieval. EHR is regarded as an effective clinical documentation tool to improve the quality of care for conditions for which guidelines are quickly … Continue reading
Read MoreMedical Decision Making (MDM) documentation is as significant as the other two components of documentation (History and Exam) in assigning an evaluation and management (E/M) service level. The end result of MDM is complexity level or severity of presenting complaint. MDM … Continue reading
Read MoreA new study by a group of researchers from the Regenstrief Institute and the Indiana University School of Medicine shows that natural language processing or NLP accurately tracks colonoscopy quality. The presence of adenomas in the colon predicts the patient’s … Continue reading
Read MoreAccurate pediatric documentation is not only essential for effective care and treatment for the child, but also plays a significant role in ensuring patient safety. A UK based study identified different types of pediatric safety incidents and found documentation-related errors … Continue reading
Read MoreAccurate clinical documentation that supports medical necessity is essential for getting proper payments for urology procedures. Medical necessity of a service is defined as an overarching criterion for payment apart from individual requirements specified for a CPT code. You should … Continue reading
Read MoreMedical transcription – a task which every healthcare institution is burdened with, and is therefore outsourced en masse, is probably heading in another direction, that of increasing automation. It would probably come as a revelation that the years from 2007 … Continue reading
Read MoreThis year, National Medical Transcriptionist Week will be celebrated from May 17 to 23. Sponsored by the Association for Healthcare Documentation Integrity (AHDI), this event mainly aims at recognizing and celebrating the contributions of healthcare documentation specialists (HDSs). The spotlight … Continue reading
Read MoreMost radiology departments have begun to transition from paper-based imaging requests to electronic orders originating in an EHR system with a view to streamlining their workflow. Access to EHRs can have a significant impact on radiology decision making. Electronic record … Continue reading
Read MoreIt is very important to maintain quality and accuracy when documenting pediatric post-take ward rounds (PTWR) since care is evaluated, and coordinated care plans are formulated during this time. This documentation task often left to junior doctors is quite challenging … Continue reading
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