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. As a private medical practitioner, it is imperative that you have an efficient system of documenting the medical records. Do not underestimate the power of efficient medical documentation in your practice and that means that you should improve it. Most of the medical practitioners with inefficient medical documentation system usually spend numerous hours putting data into an EHR. Medical documentation is a big challenge that can affect your practice and this can be made easier using certain excellent tips. The use of the software is encouraged if you want to avoid wasting time in entering data. Keep reading the article herein to learn how to improve 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. 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. The other means to improve efficiency in medical documentation is using dictation software. Once the software capture data, you should ensure that you edit the notes to ensure that they are accurate.

The use of EHR shortcuts is common, and one common idea is optimizing billing. It is common to lose on potential revenue if you go through the notes between the patients visits through under coding. Also, the risk of over coding is there, and this might 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. 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.

Finally, follow the 2-minute rule. This should come into play once you learn how to reassign documentation task and master monotasking. 2 minute rule simply means that you should handle all the task that takes less than 2 minutes now. 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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