How to Get the Most Accurate and Complete Documentation in Your EHR System?

In medicine, there is a saying that if you didn’t document it, it didn’t happen. As a medical professional, you probably focus on providing the best possible care for your patients. On the other hand, if you want to get paid for your work, you must ensure you accurately enter all information from the visit in the EHR system. You want to maximize your time with your patients, so you probably don’t want to spend more time than you should be working on electronic medical records. How can you maximize your time with your patients while ensuring all documentation in the medical record system is accurate and complete?

In this article, you will learn the following:

1. Importance of Accurate Documentation: Accurate and complete documentation in the EHR system is crucial for effective patient care, proper insurance reimbursement, specialist referrals, and research.
2. Challenges with Voice Recognition Software: Standard dictation software often results in errors, making proofreading a time-consuming necessity, which can still lead to inaccuracies in patient records.
3. Solution with Scribes and Transcription Services: Utilizing professional scribes and EHR transcription services ensures detailed, accurate medical records, allowing physicians to focus more on patient care than on documentation.

The Importance of Complete and Accurate Documentation

You must have complete and accurate documentation in your electronic medical record system for several reasons. They include:

• You need your patient records to be accurate because when the patient comes in for another visit, you need to know what happened during the first visit.
• If you do not have complete and accurate documentation, your insurance reimbursement rate might drop, meaning you are not fairly compensated for your services.
• If your patient is referred to a specialist, the specialist will ask for a copy of your medical record. It would be best to have them reflect accurately on what happened during your visit.
• If your records are used for future research studies, they must be accurate so that the researchers can draw responsible conclusions based on the information.

You need accurate documentation, but how can you expedite the process without sacrificing accuracy?

Avoid Your Standard Dictation Voice Recognition Software

Many doctors have turned to standard dictation voice recognition software to help speed up the process. There are several drawbacks to using dictation voice recognition software. They include:

• Dictation voice recognition software is still prone to a lot of errors. Even if they are 97 percent accurate, this still means that three words out of every 100 are wrong.
• It is tough to proofread dictated notes. The automatic software program always uses an accurate word, even if it is incorrect. As a result, spell check doesn’t catch these errors.
• They still take a long time because you must proofread your note carefully after dictating it.

Therefore, you must find a suitable alternative to dictation voice recognition software.

Work With Scribes and Professional EHR Medical Transcription Services Instead

If you want to save time while ensuring your notes are accurate, you must work with scribes and professional EHR transcription services instead. If you work with a professional transcription service, you can spend all your time seeing patients. Then, when you sit down to finalize your notes, they will be complete, accurate, and ready for your review.

You need to work with a virtual medical scribe and a medical transcription service because you deserve to work with a clinical professional who understands medical jargon, can work quickly, and understands the importance of accurate notes for patient care and reimbursement purposes.

In particular, you need to work with a remote scribe and transcription service. Some of the top advantages of working with a remote EHR transcription service include:

• You don’t have to worry about someone calling out sick because there is always another trained professional to cover for them.
• You don’t have to train your scribe or transcription service because a professional company will have trained them.
• You do not need to worry about them being in the room with you because they work remotely. 

For these reasons, you must work with a remote medical scribe and medical transcription service to ensure the accuracy and completeness of your medical records. That is where we can help.

Trust DataMatrix Medical for Professional EHR Transcription Services

These are just a few reasons to work with a scribe and transcription service for medical records. At DataMatrix Medical, we provide access to professional scribe and EHR transcription services. We are one of the most trusted companies in the field, and it would be our pleasure to show you why. Our team provides quick, accurate, complete documentation to expedite the review and reimbursement process. If you want to learn more about how we can help you, contact us today!