Dangers in Electronic Medical Documentation

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How to document your electronic medical records? Read more...

How to document your electronic medical records? Read more...

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  • 1. Dangers in Medical Documentation MedicalTranscriptionsService
  • 2. The many pitfalls of electronic documentation! • Slip-shoddy documentation can lead to disastrous consequences. • The shocking news of patients dying due to documentation errors, is hitting the headlines more frequently. • Patients blame physicians, medical practitioners blame poorly designed EHR systems, and EMR vendors blame the physicians’ reluctance to learn.
  • 3. Too, much of a good thing… • Extensive medical documentation can help providers survive audit scares. • But overload of medical information is scaring the daylights out of physicians. • Some notes are stored chronologically, it can take forever and a day to, locate pertinent information. • Most physicians follow the unhealthy trend of avoiding nursing notes altogether to save time.
  • 4. Hidden surprises! • Most medical practices miss out on pertinent information while making the transition from paper records to electronic ones. • Paper records, that contain important information, risk being sent to the shredding machine. • Thanks to a huge amount of omitted and incorrect information, most physicians don’t trust their electronic medical records and are inherently suspicious of the veracity of the records.
  • 5. The pitfalls of carrying forward information… • Medical practices have faced a lot of flak for sloppy pasting. • Misrepresentation of information and clinical plagiarism are on the rise due to the reckless carrying forward of information, and sloppiness. • Assuming a medical assistant sees a patient, fills in information and leaves. • The supervising physician walks in, makes a few additions to the chart and signs it.
  • 6. • It inadvertently omits the fact that a medical assistant was present. • Which tantamounts to fraud in the eyes of the insurer as it is not clearly documented, who provided the service. • There are several medical legal problems if physicians don’t exercise enough caution while documenting.
  • 7. A better understanding! • Understanding EHRs. • Instead of, hoping for EMRs to do everything but make breakfast. • Physicians should take some time to understand their systems, and educate themselves of the challenges and opportunities EMRs provide. • Customizing EMRs.
  • 8. Thank You…!!! For more details call 877-272-1572 or visit www.medicaltranscriptionsservice.com