Medical documentation is an important aspect in the healthcare industry, and over the years it has undergone several changes. Earlier, the medical record was a simple handwritten document which has now transformed into digital format. Today, healthcare units and hospitals have adopted EHR systems
The electronic health record (EHR) is designed to improve patient care and streamline physician workflow. With the widespread adoption of digitized patient records, medical transcription companies enter physician narrations directly into the EHR instead of into word processing systems. Medical transcription services ease physician
Documentation integrity refers to the accuracy of the complete health record. Clear, consistent, complete, precise, reliable, timely, and legible electronic health record (EHR) documentation is necessary to reflect the patient’s disease burden and the services provided. Outsourcing medical transcription goes a long way when it comes
Electronic health record (EHR) adoption in the United States has reached a new high at 89%, according to a recent SelectHub report. However, even as EHR systems are constantly evolving, usability issues still persist. Surveys have found that lack of user-friendliness and documentation issues
The patient problem list, a key component of the electronic health record (EHR), is a list of the important illnesses, injuries, and other factors impacting a patient’s health. American Health Information Management Association (AHIMA) defines the problem list as “a compilation of clinically relevant