In the recent past the healthcare industry has seen a lot of changes especially in the way patient encounters are documented. The proposed move towards an electronic healthcare system has driven healthcare professionals and healthcare facilities to look for ways to efficiently and economically document the care process. Point and click templates that warrant the healthcare professionals to document the patient encounter during the care process has been offered as a solution for adopting EMR/ EHR.
- Though this method offers creation of patient medical records without any time lag it has been found to have a few major shortcomings, including:
- Lack of narrative in the patient medical record
- Limiting the entries of the healthcare professional to the options provided in the templates
- Danger of repetitive data which does not have the benefit of identifying the individual medical history distinctly and his/ her problems
- Danger of wrong entry due to restrictions on the healthcare professionals’ time
- Copy and pasting of details from other records to save on time
- Taking the focus of the healthcare professionals away from their patients
- Negatively impacting the productivity of healthcare professionals
It can be concluded that though point and click template driven healthcare documentation does offer a few advantages it does not meet the criteria of quality documentation.
Medical transcription is a service that has been aiding the healthcare documentation process by creating accurate, legible, complete and timely patient medical records, which not only contain the dry facts of the patients’ medical history but also have valuable inputs of the thought process of healthcare professionals leading to the diagnosis and treatment. The specialized nature of medical transcription services has given rise to the outsourcing concept, which has further benefited healthcare professionals and healthcare facilities in terms of cost savings and better resource utilization. Outsourcing medical transcription also has the benefit of creating healthcare documentation that helps overcome the limitations of template driven patient medical records.
Some of the benefits of healthcare documentation by medical transcription services are:
Preserving the narrative: Using medical transcription to document the care process ensures that healthcare professionals can use the familiar, convenient and preferred method of data collection – dictation through modes of their choice. This ensures that patient medical records are created along with the narrative portion
Detailed records: Using the services of a medical transcription company to document the care process has the further advantage of not limiting the details recorded in the patient medical record. Healthcare professionals can dictate the unique details of the patient encounter and this will be faithfully transcribed on to the patient medical record
Accuracy: Documenting the care process using the services of a medical transcription company ensures that the information in the patient medical record is highly accurate as each transcript is put through a stringent quality process consisting of various levels.
Enabling healthcare professionals to focus on patients: Dictation –to- transcription option for creating patient medical records also offers the advantage of allowing the healthcare professional to focus totally on the patient. This not only ensures patient satisfaction but also positively impacts the healthcare professional’s productivity.
Adoption of EMR/ EHR: Medical transcription companies are experts at adapting services, processes and technology to meet the changing needs of the healthcare sector. This expertise enables them to aid in the process of adopting EMR/ EHR with services like structured dictation, structured transcription, discrete reportable transcription and HL7 interface. Using medical transcription services for EMR/ EHR adoption has the further advantage of allowing healthcare professionals to retain the narrative portion as part of the patient medical record and maximizing productivity of healthcare professionals by allowing them to focus on patients rather than on the documentation process.
It can be seen that not only does outsourcing medical transcription help overcome the shortcomings of template driven documentation but can help save on costs, increase productivity, improve risk management, quicken receivables management and aid in adoption of EMR/ EHR
TransDyne, a leader in the outsourced medical transcription industry has used their extensive background in information technology and their experience in serving the needs of the healthcare sector to provide affordable and integrated medical transcription solutions.
Among the software and tools offered by TransDyne for transcription, the smart delivery system has a large role to play in easing the path to EMR/EHR adoption The Smart Delivery system, which has features like User defined folder paths to enable easy imports to EMR systems is the suggested mode of document delivery where pre-defined file saving would help import documents to EMR systems. Apart from this TransDyne also offers discounted rates for those healthcare facilities that provide demographic data entered in the EMR rather than through other modes.
Along with medical transcription services involving multiple level quality checks to ensure accuracy, the use of the right technology for ease of use, turnaround time and security, at reasonable rates, TransDyne also provides discrete reportable transcription for adoption of EMR/ EHR
To avail complete medical transcription services from TransDyne, click here.
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