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Ways and Ideas for Efficient Medical Documentation

Quality healthcare is one of the top agendas of many states, and this requires a team of well-trained physicians and healthcare infrastructure. 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. 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. No doubt, data entry takes too much time of a doctor, and that explains why reassigning is a good idea. 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. If you cannot afford to hire a medical scribe, you should consider 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 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. Also, the risk of over coding is there, and this might lead to insurance penalties. Some of the common mistakes that can make you susceptible to under code include missing information, lack of full diagnostics, and lack of procedural specificity. Through the optimization of medical billing, all the necessary information will be captured. Additionally, ensure that you create a time schedule for monotasking.

The last tip to consider is the 2-minute rule. This should come into play once you learn how to reassign documentation task and master monotasking. It means that if the task takes less than 2 minutes, you should do it now. It is usually stressful and daunting to handle larger task, and this can be made much easier by breaking it down into simpler tasks.

Now that you understand how to improve medical documentation efficiency in your practice, you should consider it.

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