Medical records are a combination of both self-reported patient information and physicians’ notes on the diagnosis, care and treatment given to the patient. When a patient visits a physician, he or she diagnoses the patient and dictates the patient’s medical condition via a digital recording machine. Medical transcription services transcribe these recordings into accurate medical records and via HL7 interface the transcription vendors can access the physician’s EHR and upload the information. Medical records should be documented in a timely and error-free manner.
The need for accuracy in medical transcription is rising rapidly. This is due to increased demand for medical documents to ensure quick and efficient patient care. It helps the healthcare providers to come up with the most appropriate treatment plan and correctly follow it. Accurate medical records not only improve the quality of care, but also help increase revenue.
What is the Reason for Poor Documentation?
According to an article by Promptemr, $10.7 billion worth software problem in physical therapy was caused by bad software, leading to indefensible documentation and bad billing processes. This not only affects the health of the patients but also results in loss of revenue for the medical organization. Another blog published in www.rightpatient.com stated that patient identification errors have been a long-term issue in the US healthcare system.
Significance of Patient Identification
It is estimated that every year, around 195,000 deaths occur because of medical errors. Patient identification errors are a major concern in this regard. Identity theft also leads to financial loss for patients. For instance, a person who did not undergo a particular treatment could receive a bill stating that they did. Patient identity may sometimes get mixed up due to common names, age, DOB etc. This can cause a ripple effect and damage the reputation and credibility of the healthcare organization. The right solution to this issue is to improve the accuracy of medical records by hiring a reliable transcription vendor.
Documentation Tips for Accurate Medical Records and Better Revenue
Accurate medical documentation is important to protect the patient’s health. It promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. With duplicate or inaccurate medical records, larger hospitals can have more than a million records stored in their EHR systems that are of no use. It leads to mistreatment, wrong medical decisions, and wrong medications, based on inaccurate or incomplete medical history arising from duplicate records or overlays. If the patients are identified before any service, the right patient will receive the right treatment. This will help the healthcare organization to save millions of dollars.
- Set Achievable and Measurable Goals: The most common cause for denial of the claim in physical therapy is poorly documented treatment goals. So, the goal must be measurable and impact the patient’s daily life to be defensible and justify continued skilled treatment. Examples:
- Inaccurate: Improve Right Shoulder Range of Motion – 6 Weeks
- Accurate: Improve Right Shoulder Flexion Range of Motion by 20% to allow patient to reach into kitchen cabinets – 6 Weeks
- Consider Objective Measurements more Frequently: Documenting objective measurements every time a patient visits may be of no use, as the patient’s measurements may be identical. Increasing the frequency of your objective measurements will however, allow you to prove your value to your patient and get them to continue going to therapy.
- Track and Show Progress on Flowsheet: Illegible flowsheets impact the ability to treat your patients, and it can also lead to claim denial. Another issue it that it is not possible to use flowsheet to show a patient how much they progressed. An electronic flowsheet which is easy to use is a useful tool that help you get paid and also help you retain patients longer.
- Document on the Same Day: Make sure to complete the documentation while you treat the patient. The ideal practice is to have the patient fill in his/her chief complaint, primary concern, and pain levels for the day. This practice helps to create defensible documentation that is accurate and saves you from getting behind on your notes.
Accurate medical documentation is an essential element for any hospital, clinic or healthcare unit, and a professional medical transcription company can help ensure this. It consists of all important information from the admission of the patient till his or her discharge. These records become useful for the patients as well as the healthcare providers for future visits.
