Ensure Fast and Accurate Laboratory Results in the EHR with Pathology Transcription Services

Get Accurate Laboratory Results in the EHR with Pathology Transcription

EHRs have a key role in helping pathology labs meet their core task of delivering vital patient care information to health care providers.

Medical Transcription Services United States

The widespread adoption of electronic health records (EHRs) has significant implications for pathologists’ goal of ensuring that health care providers receive laboratory test results. Laboratories need to ensure that the test results and pathology reports they convey to electronic health records (EHRs) are accurate, complete, and presented in a usable format, in a timely manner. Pathology transcription services can help pathologists achieve this goal. From basic diagnostic reports, physician notes, and patient history and records to radiology reports and anatomic pathology test results, an experienced medical transcription service provider can ensure quality pathology-related documentation.

EHRs have a key role in helping pathology labs meet their core task of delivering

vital

(HealthIT.gov).

patient

care

information

to

health

care

providers

EHR implementation has transformed the way lab

information is communicated and translated into clinical action and is transforming the practice of medicine and health care information management. Widespread EHR adoption offers opportunities to, and makes

it

necessary

for,

pathologists

to

take

on

transformative

professional roles and duties.

Importance of Verifying Pathology Reports in the EHR A College of American Pathologists Q-Probes Study published in the Arch Pathol Lab Med. Sep, 2016 highlighted the importance of validating lab test results in the EHR. The study stresses that all results, reference information, and other report elements needs to be presented in a visually easily understandable format. All report elements should be easy to find, clearly labeled, and properly aligned.

The researchers reviewed results for a wide variety of laboratory tests such as tests performed by most laboratories, tests sent to reference labs, tests with numeric and textual results, manually entered results, www.medicaltranscriptionservicecompany.com

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automatically resulted, and anatomic pathology reports, including surgical pathology and cytology. These included: creatinine, corrected platelet count, hemoglobin A1c, international normalized ratio, blood bank antibody screen, blood culture with sensitivities, estimated glomerular filtration

rate,

human

immunodeficiency

virus (HIV-1)

quantitative

polymerase chain reaction assay, serum protein electrophoresis, EpsteinBarr virus viral-capsid antigen immunoglobulin (Ig) G antibody, factor V Leiden mutational assay, breast estrogen receptor studies, surgical pathology report with synoptic component, Papanicolaou cytology report with human papillomavirus result, etc.

The study found that only a relatively low percentage of labs verified the transmission of data to the EHR at least once a year or every other year.

While electronic interfaces allow more rapid and accurate transmission of test results, the researchers point out that it is critical that labs review transmitted results to ensure they are complete, accurate, and in a maximally usable format. They stressed that test results need to be reviewed “before going live with a new interface that transmits results to the EHR, when changes are made at the laboratory or EHR level that could alter test resulting, and periodically”. According to the CAP Laboratory General Checklist, the CAP laboratory director should review and approve the content and format of paper and electronic patient reports at least every two years.

Pathology Transcription Services EHR-integrated medical transcription services allow laboratories to display test results to meet Meaningful Use requirements. Error-free pathology reports are a crucial element in healthcare organizations’ efforts to improve health care quality and meet the federal government’s goals and objectives for EHRs, which include www.medicaltranscriptionservicecompany.com

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

Identify needed lab tests



Receive notifications about lab values outside normal ranges



Enhance their ability to better manage incoming lab results



Recognize and target patients with abnormal lab results for followup care



Ensure better availability of lab results to help organizations order fewer tests



Allow clinicians to order lab tests electronically, which will improve care coordination

EHRs also allow labs to provide patients access to routine lab results including complete blood counts (CBC), cholesterol results, and standard chemistries.

Medical transcription companies can provide accurate EHR-integrated transcripts of different types of pathology reports such as: 

Anatomical pathology



Clinical pathology



Molecular pathology



Dermatopathology



Forensic pathology



Transfusional medicine



Hematopathology and Oncopathology



General / Investigative pathology

By helping laboratories collect and display test results to meet Meaningful Use

requirements,

EHR-integrated

transcription

services

help

healthcare organizations improve health care quality. They can provide lab test reports with all the necessary information: o Patient's name and identification number or a unique patient identifier and identification number www.medicaltranscriptionservicecompany.com

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o Name and address of the laboratory location where the test was performed o Test report date o Test performed o Specimen source (as appropriate) o Test result along with the units of measurement or interpretation, or both (if applicable) o Any information about the condition of the specimens that do not meet the laboratory's acceptability criteria Leading medical transcription companies have documentation experts who can provide accurate transcripts of pathology dictation for integration into the EHR. With competency in pathology terminology to ensure accurate test reports, experienced medical transcriptionists can identify errors or inconsistencies in dictation and makes the necessary corrections.

Reliable pathology transcription service providers also have stringent quality checks in place to ensure that the reports they deliver are accurate and meet EHR documentation requirements.

www.medicaltranscriptionservicecompany.com

918-221-7809