Why Good Medical Documentation is Important

Dr. Julie Taitsman, Chief Medical Officer for the US Department of Health and Human Services, highlighted the importance of good medical documentation in a recent podcast. She stressed three reasons why good medical documentation is so important. Good medical documentation:

  1. protects our healthcare programs—”Accurate documentation ensures the federal health care programs pay the right amount—not too much and not too little—to the right people.”
  2. protects your patients—ensures that “your patients get the right care at the right time.”
  3. protects you, the provider—”Good documentation can help you avoid liability and keep out of fraud and abuse trouble. If your records do not justify the items or services you billed, you may have to pay that money back.”

Is Record-Keeping Overloading Your Practice?

A study reported in the Annals of Internal Medicine summarized “approximately 100 million patient encounters with 155,000 physicians.” The study reported that physicians spent an average of 16 minutes and 14 seconds per encounter with the following functions accounting for most of their time:

  • chart review (33%)
  • documentation (24%)
  • ordering (17%)

Then there is this article on the American Medical Association website by Tanya Albert Henry. The author referred to another study in a Medscape Physician Compensation Annual Report. The survey found that 70% of the physician respondents “spend 10 hours or more weekly on paperwork and administrative tasks.”

So, in your quest for good (and compliant) documentation, you are spending a large portion of your working day on administrative tasks that could be consolidated, delegated, and outsourced—and free up your time and attention to treating your patients.

Here is where outsourced medical scribes become part of the solution.

The Benefits of Medical Scribes

In this AMA article, author Andis Robeznieks describes how medical scribes benefit your practice beyond just reducing data-entry time.

Medical scribes “are professionals who transcribe information during clinical visits in real-time into electronic health records (EHRs)…” Scribing “allows doctors to focus on the patient…(and) results in lower physician documentation burden and improved efficiency, workflow and patient-physician interaction…”

The Problems of Documentation and Transcription

If you hire a full-time medical transcriber (or scribe), your current workflow begins with creating an audio record of a patient treatment session. Using the team documentation method, your in-house staff of professionals work as a team and free up physician time for better patient care, but with the disadvantages of added personnel costs.

What are medical transcription services?

Outsourced medical transcription services consist of a team of “virtual medical scribes” specially trained in medical documentation. They deliver your clinical documentation to your electronic health records system seamlessly.

The Datamatrix Medical Solutions team of scribes, for example, delivers completed medical transcription with a turnaround time of as little as two hours and a 98% accuracy rate.

The beauty of outsourcing is that what was once an in-house workload burden instantly becomes a worry-free, professionally managed external solution. Outsourcing your medical transcription services:

  • reduces operating and maintenance costs
  • allows physicians to focus on patient diagnosis and treatment
  • frees up time for longer patient visits because of less time having to be spent on paperwork
  • takes advantage of a pool of highly trained medical scribes, who completely focus on note-taking, focusing on details, and leaving less room for errors
  • restores comfort to patients*

*Note: Practices that opt towards having an in-house scribe could unintentionally make patients uncomfortable. Frequently, the transcriptionist must be present in the exam room while the patient is discussing personal and delicate medical information.

More Benefits in Outsourcing Your Medical Scribe Services

Also, outsourcing medical transcription services has the following additional benefits:

Patient interactions are improved

When physicians spend less time on their laptop computer with the assistance of a scribe, patients are more confident and relaxed. That extra measure of full attention improves the physician-patient relationship.

Physician burnout is reduced

One of the ironic effects of the digital age is that the information age has not lived up to its promise of reducing work. Electronic health record documentation, patient privacy requirements of HIPAA, and liability concerns have ganged up on the medical profession. Using scribes won’t overcome EHR glitches, but expert medical data entry can reduce the pressure on overworked medical care professionals.

Adds the human touch to EHR

When your practice outsources its medical transcription service, you have a real person interpreting and transcribing medical records, not a machine. Unlike voice recognition systems, a medical scribe can understand medical terms when human nuances and background noise interfere. Because of this, your medical team will have accurate, effective, and consistent electronic health records.

Yes, technology is the future. However, some things need a human touch. The quality of your stored electronic health records should not suffer due to impersonal technology. An outsourced medical scribe will be devoted to your practice and its patients. That human touch will be reflected in higher quality EHR.

Is an Outsourced Medical Transcription Service Right for Your Practice?

To recap, an outsourced medical scribe can benefit any practice, no matter how large or small by:

  • saving your physicians’ time and your practice’s money to allow your practice to grow
  • enabling smoother and more efficient communication between team members to guarantee patients the care they deserve
  • allowing physicians to get more one-on-one time with their patients—reinforcing the reasons they chose to be a doctor in the first place

Not convinced yet? Ask yourself the following:

  • How important are accurate and consistent medical records to my practice?
  • Would my physicians benefit from more time and less paperwork?
  • Do I value the benefits of employing a human medical scribe?
  • How would more money spent on patient care help my practice grow?

If your practice is ready to explore the benefits of a medical transcription service, we want to help talk you through it.

To learn more about how outsourcing medical transcription services can help your practice, download our free guide, How To Optimize Clinical Productivity Through Outsourcing.

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