Author Archives: Julie Clements
EHR Deficiencies in HIMSS Survey and the Need for Medical Transcriptionists
Most providers are transitioning to EHR technology owing to the EHR incentive program, and they must be sure of their clinical documentation integrity. A 2014 survey by the Healthcare Information and Management Systems Society (HIMSS) found severe deficiencies with EHR … Continue reading
Read MoreRecent Trends in Telemedicine
Telemedicine, the actual delivery of remote clinical services using technology, is growing rapidly. According to a report by Research and Markets, the global telemedicine market is expected to increase by a compound annual growth rate of 18.5% through 2018. The … Continue reading
Read MoreEHR for Reducing Hospital-acquired Infections in Pediatric Care
A complete and accurate reporting of all hospital-acquired infections (HAIs) is critical in pediatric care as HAIs are associated with longer hospital stays, longer ventilation times, increased cost and adverse neuro-developmental outcomes in children. Electronic health records or EHRs are … Continue reading
Read MoreCollaborative Depression Care for Pregnant Women, What’s the Role of Documentation?
Untreated depression during pregnancy can lead to poor nutrition, drinking, smoking, and suicidal behavior in mothers and also result in premature birth of the baby, low birth weight and developmental problems. A study published in Obstetrics & Gynecology (June 2014 … Continue reading
Read MorePhysicians and EHR – How to Save their Relationship
As the adoption of the electronic healthcare system gathers pace, healthcare providers are adopting EMR/EHR to achieve meaningful use objectives. The main benefits of electronic health records are easy sharing of patient information, improved security of protected health information (PHI) … Continue reading
Read MoreBetter EHR Systems and Documentation for Ebola and Other Infectious Diseases
With the Ebola outbreak, the efficiency of electronic health records (EHRs) in handling infectious diseases has been questioned. This October, representatives from the Centers for Disease Control (CDC) and the Office of the National Coordinator for Health IT (ONC) co-hosted … Continue reading
Read MoreTranscribing 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
Read MoreChanging Role of Medical Transcriptionists with EHR Implementation
The pressure for EHR (Electronic Health Record) adoption is increasing, thanks to the incentives assured and warnings of reimbursement cuts. Though electronic clinical documentation is said to reduce the relevance and significance of medical transcription, the truth is that EHR … Continue reading
Read MoreLaryngeal Cancer Surgery – Why Proper Documentation is Vital
Surgery is a commonly used treatment option for patients with laryngeal cancer. However, the effectiveness of this option depends also on proper surgical documentation. Though there are different surgical operations used to remove the cancer (for example, laser surgery, laryngectomy, … Continue reading
Read MoreWhy Documentation of Vital Signs in Emergency Departments Should Be Consistent
Though the monitoring of vital signs (heart rate, respiratory rate, temperature, blood pressure, peripheral oxygenation and pain) is a commonly performed task in emergency departments (EDs), there are no published standards of care that provide appropriate guidelines for the frequency … Continue reading
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