EMR helps improve the quality of medical records greatly.
We have come across dictations that talk about a patient’s workplace, and normally we go to a lot of websites to find the name of the company. All the searches may or may not provide the accurate information, but most of the times we find the info correctly.
The same holds true when it comes to transcribing family history of a patient. We have no clue whatsoever if the patient’s parents are alive or not, or if they have any of the dictated medical conditions. So we just go by what is dictated. A little input about the patient’s family from some other source would have helped. HIPAA does not allow that. So again, we do verbatim transcription.
Even more serious risks await us when we transcribe the patient’s medications, allergies, past medical and surgical history. We have a contractual obligation to transcribe what is dictated, but does that mean what is dictated is accurate 100% of the time? I would say 97% of the time doctors dictate correctly. But the little numbers that they dictate; the lab values, the medication dosages, age of the patient, etc., are the traps most of the time. My experience is, 1 in 10-15 reports contain such errors. Such errors in transcripts cost the doctors dearly because insurance companies deny such claims.
So, how do we know what is dictated is incorrect? For a conventional transcriptionist, there is absolutely no way to find this out. However, someone who works in EMR knows everything about the patient. Hence even if the doctor dictates “the patient underwent hysterectomy in 2005,” he can go back to the patient’s chart to verify if the patient actually underwent hysterectomy in 2005. What if the dictated information is incorrect? What if the patient did not undergo hysterectomy in 2005? If EMR contradicts the doctor’s statement, then EMR wins! You trash what is dictated and go with the data in EMR. In the process, quality is the winner. Such accurate information helps the claims department to reduce denials to a great extent.
This is just one of the many contributions that EMR makes to quality healthcare documentation. We will see more of this later.
We have come across dictations that talk about a patient’s workplace, and normally we go to a lot of websites to find the name of the company. All the searches may or may not provide the accurate information, but most of the times we find the info correctly.
The same holds true when it comes to transcribing family history of a patient. We have no clue whatsoever if the patient’s parents are alive or not, or if they have any of the dictated medical conditions. So we just go by what is dictated. A little input about the patient’s family from some other source would have helped. HIPAA does not allow that. So again, we do verbatim transcription.
Even more serious risks await us when we transcribe the patient’s medications, allergies, past medical and surgical history. We have a contractual obligation to transcribe what is dictated, but does that mean what is dictated is accurate 100% of the time? I would say 97% of the time doctors dictate correctly. But the little numbers that they dictate; the lab values, the medication dosages, age of the patient, etc., are the traps most of the time. My experience is, 1 in 10-15 reports contain such errors. Such errors in transcripts cost the doctors dearly because insurance companies deny such claims.
So, how do we know what is dictated is incorrect? For a conventional transcriptionist, there is absolutely no way to find this out. However, someone who works in EMR knows everything about the patient. Hence even if the doctor dictates “the patient underwent hysterectomy in 2005,” he can go back to the patient’s chart to verify if the patient actually underwent hysterectomy in 2005. What if the dictated information is incorrect? What if the patient did not undergo hysterectomy in 2005? If EMR contradicts the doctor’s statement, then EMR wins! You trash what is dictated and go with the data in EMR. In the process, quality is the winner. Such accurate information helps the claims department to reduce denials to a great extent.
This is just one of the many contributions that EMR makes to quality healthcare documentation. We will see more of this later.
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