In Medical Transcription services, there is a false belief that all medical practitioners can provide a right documentation. Doctors or healthcare providers may document inaccurately due to many reasons. We would also like to add that, for a patient to attain a right way of medication and treatment, the documentation should also be accurate. So now, you will be wondering how documentation errors can be completely avoided. A Medical Transcription Service Provider like iTranscript 360 with 100% accuracy in Transcription can only detail you about this.
Here are some of the steps to avoid error documents at your medical practice for preventing adverse effects on patients.
Since the number of patients visiting a day can be high, documenting a detailed record of every patient is mandatory rather than noting the basic information. The medical record should include patients medical history, reason of visit, diagnosis, planning the treatment, test results if any etc. An incomplete medical record can result in missed important information and can adversely affect the patient.
The Medical practitioner should be alert on noting down the health risk factors of every patient on each visit. This is to know more about the response of the patient’s body to a particular treatment or an intended way of treatment.
“Present illness history documentation” is very important tip for a medical practitioner to note down the history of present illness in a patient. Most of the healthcare providers are very confident about their patient’s present illness reason to be memorized and where they forgets during the next visit and the history of present illness have to be found out again.
- A detailed explanation of the System review should be considered rather than a extensive sketch.
As every patient is not same a different approach is needed for diagnosing a disease and planning a treatment, a detailed report on the criterion used for the treatment should be necessarily done. This means a medical practitioner should detail about the “what”, “why” and “how” treatment is fixed in the report.
Using the structured templates to prepare the documents can lead to a dangerous problem as far as a patient is considered. This is because if two patients with a same disease has visited, a structured template for detailing “what”, “how” about treatment leads to confusion and medical necessity cannot be claimed. Thus, computerized documentation is not at all preferable.
Spending more time with a patient for counseling can improve your payment and you will get to know more about the patient and thus documentation which is evidence based can be produced
Medical practitioners should ensure to educate their staff for a better documentation
Don’t try to prepare a documentation after a tiring day. Find a separate day for detailed documentation. While patient visit, try to have a skeleton work of document done and on the day assigned for documentation, you can elaborate on the basic information you have done before. This will lead to less error and documentation mistakes.
A false documentation can adversely affect the patient in all his ways and this can also affect their credibility in the medical practitioners service history. Nowadays, this is why medical practitioners and healthcare providers approach Medical Transcription service providers for a better documentation. If their works are given to Medical transcription services, they can expect a better documentation from the service provider side and can sit back in a relaxing manner.
An incorrect documentation can be named as silent killer as many patients are getting affected due to improper documentation. So, to avoid risk in documenting, try approaching a Medical Transcription service provider like iTranscript 360.