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Importance of Precise Medical Documentation and Transcription Inaccurate medical documentation puts the health of patients and the future of your practice at risk.

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Errors in medical transcription and medical documentation put patients’ lives at risk and lead to huge penalties for physicians as well as loss of reputation and revenue. With their busy schedules, physicians may overlook key aspects of documentation, causing errors to creep in.

Errors in Medical Documentation Are Costly Documentation errors adversely affect patient care, and in many cases, even prove fatal. Errors in medical documentation are the third major cause of patient deaths, following heart disease and cancer. An IOM report states that preventable adverse effects are the cause of death for 100,000 Americans each year. Medical errors are also costing a trillion dollars each year for the nation. The complex EHRs take much of the blame, but failure of practices to improve documentation practices can be pinpointed as the real reason behind costly errors. 

Incomplete medical records can cause major issues. Many practices still enter the basic information alone. The issue has become worse with computerized documentation. Structured templates do not describe medical conditions accurately. This could also cause repetition, which would affect payment for your services and also make it difficult to claim for medical necessity.

Health risk factors need to be clearly identified in medical records. The way the patient responds to the treatment should be described along with any changes made to the original treatment plan. The criterion for treatment decisions need to be detailed so as to support medical necessity.

Documentation of the HPI (history of present illness) and the inclusion of the CC (chief complaint) are essential. These are typical areas where physicians do not focus on the details, though they should.

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Data Duplication - A Serious Issue Data duplication must be avoided at all costs since it could have pretty adverse consequences. Many physicians, burdened by hectic schedules, indulge in the “cloning” or the “copy and paste” practice which leads to copying patient notes carelessly. This could result in inaccurate information which will not only seriously hurt patient treatment, with the possibility of fatalities, but also attract massive penalties. The HHS (Health and Human Services) views such practices very seriously as it warned back in September 2012.

This practice, whether done intentionally or unintentionally, could result in duplication and inaccurate claims. Auditors and payers scan claim details carefully and detection of such malpractices would result in massive penalties and denied claims.

Trained Staff for Precise Documentation Many documentation issues occur because practice staff lack proper training. Billing and coding staff must be specifically trained in EHR systems to prevent inaccurate and incomprehensive documentation. That may sound extensive and resource consuming, but it is critical to ensure that the tasks is handled only be experienced personnel to ensure proper documentation and a better future for your practice, not to mention the welfare of your patients.

It also helps to schedule your medical records documentation on workdays where you are least busy. You can first add basic information and then add the details and build on it later. While this isn’t ideal always, it can help prevent errors in the factual information, taking away the chance of fatigue interfering with precise reporting. Accurate transcription is also vital to ensure these errors do not creep in. Outsourcing medical transcription to the right provider does make the difference.

www.medicaltranscriptionservicecompany.com

800-670-2809

Importance of Precise Medical Documentation and Transcription  

Inaccurate medical documentation puts the health of patients and the future of your practice at risk.

Importance of Precise Medical Documentation and Transcription  

Inaccurate medical documentation puts the health of patients and the future of your practice at risk.

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