6 Ways Physicians can Improve Dictation Efficiency
Clear, accurate and timely medical records are essential to support patient care. Physicians need to relay precise and accurate data to the other members of the patient’s care team. Dictated reports are usually sent to a third party for transcription. One problem that teams in
How to Ensure Your Documentation Meets the MEAT Criteria
According to ICD Coding Guidelines, all conditions co-existing at the time of the encounter that require or affect patient care and management must be clearly documented and assigned a diagnosis code. Each diagnosis must be documented clearly and precisely by the physician based on the
Medical Documentation of Burn Injuries
For successful treatment of burns, adequate documentation is a major concern. Up-to-date burn injury documentation brings more challenges and requirements for practices. Emergency departments can consider outsourcing medical transcription to get accurate reports of the treatment recordings.
Studies have highlighted that although traditional paper-based documentation
2023 HIPAA Compliance Checklist for Small Medical Practices
Enacted in 1996, the Health Insurance Portability and Accountability Act aims to ensure that PHI is protected while providing patients with better access to their health data. Protected health information (PHI) is any information in the medical record or designated record set that can
How Can You Improve Clinical Documentation?
Clinical documentation comprises all the information relating to each patient’s encounters with a healthcare facility. This information is entered in the medical record by a member of the patient’s healthcare team – a physician, nurse, therapist, dentist or other healthcare professional. Chronologically documenting this
