Jun 23, 2010 Templates and Dictation Here is my question. When he dictates his Review of System, he is only listing 3 to 4 yet his template is filled out with either negative or positive (with additional comments) for all 10 ROS. If you send your dictation template in with the dictation, they will probably count that ROS as well. In the future, just have him add to the end of the 3 - 4 systems he does dictate, 'otherwise ALL other systems are negative.' This will give his dictation credit for a complete ROS everytime. Please note: All identifying information has been omitted from our sample reports to protect privacy of patients involved. Medical reports on our site are to be used for reference purposes with no guarantee of accuracy, for research of medical words, terminology and phrases. Please be aware that style, abbreviation expansion, and verbatim preferences vary from client to client, and therefore our sample reports may not demonstrate proper Medical Transcription Style. Before submitting any work, you should consult your Book of Style, client, or instructor for further direction. No copy of this material in whole or in part is to be made without written permission. |||| October 2013 Template-Dictation Combo A Winner By Marilyn Trapani For The Record Vol. 7 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? Medical records directors and committees across the country are wrangling with this predicament while hoping to keep costs in check. While transcription departments still consume a large part of hospital budgets, they also can be the largest source of consistent reimbursement. 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. An Old Standby New technology is enthralling, but sometimes it comes at a cost. 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. Free download south indian mp3 songs. 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. Framework for Success 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. Because coding for maximum reimbursement is the goal of any financially responsible hospital, the final transcribed report is the lifeblood of success. Missing or incomplete information can delay reimbursement and require excessive queries by other practitioners to complete care and billing. The appropriate use of templates guides the practitioner to ensure that all components of care are documented. ICD-10 requires the collection and documentation of greater amounts of data, creating more opportunity for errors. Because physician dictation generally is a narrative without regard to templates, a well-crafted template requires a transcriptionist’s input to ensure that details are documented under the correct sections of the report. In a voice recognition environment, it is imperative to have a transcriptionist review and edit the document to make sure dictated information is placed within proper headings for each template design.
0 Comments
Leave a Reply. |