Author Archives: Rajeev Rajagopal

What are the Documentation Requirements for the Anesthesia Record?

Table of ContentsImportance of the Anesthesia Record Anesthesia Record Documentation EssentialsConsequences of Missing/Wrong Information in Anesthesia Record Documenting anesthesia care in the patient’s medical record accurately and thoroughly is essential to communicate the patient’s anesthetic experience. The anesthesia record should … Continue reading

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How Medical Transcription Services Help Dentists To Have Accurate Medical Records

Table of ContentsAdvantages of Using Medical Transcription in DentistryConsider Some of the Following Steps to Document Dental Records Given the importance of clinical documentation and record keeping in providing optimal patient care, it is an essential component of practice management. … Continue reading

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Why Is Patient Education Important In Healthcare?

Table of ContentsReasons why Patient Education is ImportantKey Patient Education StrategiesBest Practices for Patient Education Ignorance may be bliss sometimes, but not when it comes to patients. Patients should be educated to be proactive about managing their health. Patient education … Continue reading

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Documentation Tips To Get Clinical Notes On Time

Table of ContentsSignificance of Accurate Medical DocumentationEffective Medical Documentation Tips: Reviewing accurate and current medical records enables clinicians to skip repetitive patient questions, initiate treatment promptly, and minimize the risk of errors at all costs. Not only is it crucial … Continue reading

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What Are The Different Parts Of A Medical Consultation Report?

Table of ContentsPurpose of Consultation ReportsSpecifications in a Consultation ReportTips to Write a Consultation Report When a doctor refers a patient to another doctor, they typically receive an order for a consultation report. The consulting doctor is an expert in … Continue reading

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What Is EHR Note Bloat And How Can You Avoid It?

Table of ContentsReasons for EHR Note BloatHow to Avoid Note Bloat Medical record keeping has evolved over the years. Formerly, physicians dictated their notes and got the spoken reports converted into hand-written or typed notes by a medical transcription service … Continue reading

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Falling Behind On Patient Documentation? How To Complete It In Time

Medical records comprise different types of documentation on patient history, clinical findings, diagnostic test results, preoperative care, operation notes and discharge summaries. Completing patient documentation on time is a major challenge for busy healthcare providers. This is all the more … Continue reading

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How To Document A Good Radiology Report

Table of ContentsWhat is a Good Radiology Report? Unstructured Reporting vs Structured Reporting Accurate radiology reports clearly communicate chronic incidental findings, the diagnosis or differential diagnosis, the clinical implications of radiologic findings, and any chronic findings that need additional workup … Continue reading

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What Are the 15 Main Components of a Complete Medical Record?

Table of ContentsWhat Is a Medical Record and Why Is It Important?Legal Significance of Having a Medical RecordKey Elements of a Medical Record Medical records are a crucial resource containing all the information about a patient’s health condition, medical history … Continue reading

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How To Ensure Accurate Pathology Documentation With Medical Transcription Service

Pathologists are medical professionals that diagnose and research diseases using a variety of laboratory techniques. With the aid of medical transcription services, conversations between doctors, pathologists and patients, and medical histories and other vital information, can be recorded and transcribed. For … Continue reading

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