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A Guide On How to Improve Medical Documentation

Quality healthcare should be given priority in all the states, and this is possible if all the infrastructure are available, and the doctors and nurses are well-trained. As a private medical practitioner, it is imperative that you have an efficient system of documenting the medical records. In many health centers, poor documentation is a big issue that should be addressed. According to research, an average doctor spends less of the weekly working hours entering medical records into an EHR. It is important to note that there are several ways through which you can improve the efficiency of your medical documentation systems. The most common way to improve data entry efficiency is the use of EHR software. Here are some of the ideas and ways for efficient medical documentation.

The most useful tip to employ is delegating the data entry role. As mentioned earlier, data entry can consume a significant amount of your time hence you should consider reassigning the time-consuming task. Ensure that you find an individual who is proficient with verbatim transcription of the patient visit and data entry into the EHR. In most cases, medical doctors opt for a medical scribe, but this can be costly. Alternatively, you can consider the use of dictation software. However, you will have to create some time to summarize and edit the notes transcribed by the software.

The use of EHR shortcuts is common, and one common idea is optimizing billing. Most medical practitioners lose revenue through under coding, and the risk is high if you check the medical records between the patient visits. Overcode is also possible, and this can lead to insurance penalties. Medical practitioners end up with an under coding issue if they miss certain vital information, fail to provide full diagnostics, and the absence of a procedural specificity. Through the optimization of medical billing, all the necessary information will be captured. To ensure that you focus on a single task all the time, you should create a time schedule.

The last tip to consider is the 2-minute rule. Once you reassign some of the documentation tasks that consume your time and adopt a time schedule, you should consider adopting the 2-minute rule. Using the 2-minute rule, you will get to reduce your workload as you will take care of the tasks that take less than 2 minutes immediately. Also, you should consider breaking down the large daunting tasks into small ones.

Using the above-discussed ideas and tips, you will be sure of an efficient medical documentation process.
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