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A Guide On How to Improve Medical Documentation

Governments give priority to quality healthcare delivery by training medical practitioners and providing the necessary healthcare infrastructure. One of the tasks that you will face as a medical practitioner is the entry of medical data of the many patients you see every day. Poor medical documentation can greatly affect your practice, and that means it should be addressed. Most of the medical practitioners with inefficient medical documentation system usually spend numerous hours putting data into an EHR. Fortunately, there are ways through which you can boost the efficiency of your medical documentation system so that you can get more time to attend to patients. The most common way to improve data entry efficiency is the use of EHR software. Keep reading the article herein to learn how to improve medical documentation.

To begin with, you can create more time to perform your medical duties by delegation some of the duties. As mentioned earlier, data entry can consume a significant amount of your time hence you should consider reassigning the time-consuming task. The decision to hire an individual to help with the task should be made after examining the capability to transcribe data and enter it into the EHR. According to the experts, the right professional to hire is a medical scribe, but this can be an expensive approach. Alternatively, you can consider the use of dictation software. The use of dictation software is a good idea, but you should boost the accuracy of the data captured by summarizing and editing the notes.

The other way to boost the efficiency of medical documentation is optimizing billing, and this is an acceptable EHR shortcut. If you under code, you risk losing potential revenue, and this is likely to happen if you go through the notes between the medical visits. In the event of over coding, you might end up paying a lot of penalties to the insurance companies. The common causes of under code include lack of full diagnostics, lack of procedural specificity, and missing information. Optimizing billing will ensure that you do not miss or forget some of the critical details. Multitasking can compromise the efficiency of medical documentation, and this can be avoided by creating a time schedule.

Lastly, you should implement the 2-minute rule in your documentation process. 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. It means that if the task takes less than 2 minutes, you should do it now. Everyone finds it had to handle large stressful tasks and the best way to handle them is breaking them into smaller and simpler tasks.

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

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