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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. 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. It is important to note that there are several ways through which you can improve the efficiency of your medical documentation systems. The most common way to improve data entry efficiency is the use of EHR software. The article herein will discuss some of the excellent tips you should employ to achieve efficient 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. 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.

Next, you should consider optimizing billing, which is a common EHR shortcut. It is common to lose on potential revenue if you go through the notes between the patients visits through under coding. Overcode is also possible, and this can 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. Optimizing billing will ensure that you do not miss or forget some of the critical details. Additionally, ensure that you create a time schedule for monotasking.

Finally, follow the 2-minute rule. The 2-minute rule should be adopted as soon as you understand the idea of monotasking and delegating duties. 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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