Author Archives: MTS TEAM

Good Documentation Practices to Ensure Quality Nursing Care

Accurate and comprehensive nursing documentation is critical to provide superior quality care to patients. Quality care can be ensured with excellent team effort. Nursing charts should be easily accessible to physicians and other clinicians to help them understand the status … Continue reading

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EHRs Ring a Bell about SOAP Notes

The shift to electronic health records (EHR) has brought about some resistance and fuss from physicians and practices, but at the core of this innovation are the goals of data security, and simplicity but effectiveness of patient information entry and … Continue reading

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Documentation Requirements for Annual Wellness Visit

The Annual Wellness Visit (AWV) is a yearly appointment that provides the opportunity for healthcare providers to develop and update a personalized prevention plan for their patients. Medicare covers Annual Wellness Visit if the patients have had Medicare part B … Continue reading

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EHR Replacement Increases in 2015

According to the 2015 EHR Software BuyerView report by Software Advice, a company that researches and provides review on software applications, found that most buyers of EHRs are choosing to replace their existing system. In their six years of research … Continue reading

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Disparities in Electronic Charting of Allergy Information – Is EHR Transcription a Better Option?

Can electronic medical records eliminate the need for accurate medical transcription? This is a question frequently asked by providers who are used to dictating their medical notes and having them professionally transcribed. Let us consider this in the light of … Continue reading

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Pediatric Documentation for ICD-10

Being a specialty that already has a low financial margin, pediatric practices must ensure increased specificity in the documentation of their findings to avoid financial setback just after ICD-10 implementation. If pediatricians continue to follow the same documentation practice they have been … Continue reading

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Better Discharge Summaries to Reduce Hospital Readmission Risk

Discharging patients from the hospital is a complex and challenging process.  Every year, over 35 million hospital discharges occur in the United States. When a patient moves from an acute care setting to other levels of care such as a … Continue reading

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How to Prevent Pathology Documentation Errors

A pathology report is an important document that guides diagnostic and prognostic decisions. Accurate documentation of pathology reports is therefore critical to provide appropriate and high-quality patient care. Outsourcing to reliable medical transcription services helps in generating error-free pathology records. … Continue reading

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EHRs Not Sufficient to Improve the Quality of Stroke Care

Electronic 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

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How to Properly Document Medical Decision Making (MDM)

Medical 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

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