More with Marilyn: Template-transcription combo saves time, maintains compliance

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More with Marilyn: Template-transcription combo saves time, maintains compliance

By Marilyn Trapani

In an era when the amount of health care information astounds, providers find themselves in a quandary: How do they ensure complete patient information is communicated to medical records, coding, and third-party payers? How do they integrate clinical documentation improvement and incorporate all of the changes needed for ICD-10 implementation while still giving clinicians the information they need for patient care?

In an EMR environment, physicians can enter information into the system manually, dictate portions of documents, and copy historical information from one document to another. It can be complicated, making compliance more difficult.

The physician must manipulate historical records, attempt to dictate, and incorporate the transcribed section into the same document while using check boxes that may or may not be descriptive of a particular patient. Physicians intend to create a complete record, but sometimes their good intentions fall short, and the medical records department must wait patiently for them to complete the process.

The complex nature of some cases generally is not reflected in an EMR’s check boxes. If physicians spend two to three hours per day coordinating partial dictation with historical sections of documents, patient care will suffer. Fewer patients will be seen, fewer procedures performed, and less revenue generated. There also are compliance concerns involving getting physicians to actually complete the tasks. It may result in hospitals paying clerical staff to chase down physicians to gather the information necessary to complete records.

One possible solution to maintaining timely, accurate data is utilizing full dictation and transcription with EMR modules identifying compliance problems. It remains the most efficient and time-saving system for physicians to complete medical records without changing their workflow. Dictation is simple, a process that can be accomplished at any time through multiple mobile applications as well as by telephone.

Designed by medical records committees and approved by physician leaders, templates for report types can be created to meet ICD-10 requirements. Trained physicians dictate the necessary information, and a transcriptionist enters the data into a concise file format. If an organization opts for partial dictation, the report’s transcribed section can be uploaded via a Health Level Seven International format to the chosen EMR and melded to the check-box information that the physician selected to begin the process.

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