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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 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.

To begin with, you can create more time to perform your medical duties by delegation some of the duties. The reason why you should consider reassigning the task is because of the fact that it is time-consuming. Before you entrust an individual with the task, you should ensure that he or she is proficient with the transcription of medical data and capable of entering data into the EHR. The ideal professional for the job is a medical scribe; however, this can be expensive for some of the medical practitioners. The other means to improve efficiency in medical documentation is using 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 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. 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. To ensure that you focus on a single task all the time, you should create a time schedule.

Lastly, you should implement the 2-minute rule in your documentation process. 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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