These services provide benefits such as the following. This helps avoid claim delays and denials as well as costly litigation. With a good EHR-integrated medical transcription service, each and every record is checked and clarified to ensure they are error-free. They will stay HIPAA-compliant and help avoid legal risks.Įlectronic health records that are not properly designed and used can cause inadvertent errors such as dosing errors, loss of data, failure to diagnose serious illnesses, treatment delays and so on. However, a medical transcription company providing EHR-integrated medical transcription will help physicians, practices, and healthcare facilities meet all the medical-legal requirements for their electronic health record system. Another point to remember is that automated medical transcripts may have issues such as missed diagnosis, wrong lab results, patient mix-up, juxtaposition errors, template errors and so on. Not all EHR systems may have automated transcription feature that is legally valid. Therefore, it is important to reach out to an experienced, professional medical transcription company that can deliver international standard medico legal transcription with the highest accuracy and quality. The toughest part of medico legal transcription, whether done in-house or whether outsourced, is transcribing unfamiliar medical terminology that is an integral part of medical records. Given the medical record’s value as a legal document, accuracy is paramount. When physicians prefer to dictate their treatment notes, consult notes, progress notes and so on, these have to be accurately transcribed and details entered into the electronic health record system. In short, the medical record is an essential part of any healthcare provider’s practice.Įlectronic Health Records May Be Error-prone The medical record is also critical for patients who are involved in litigation as it provides a clear and detailed account of what happened during the treatment. In case of any malpractice, legal experts regularly refer to the medical records to determine the quality of care that was provided and whether or not the accepted standards were followed. The medical record is a reflection of what occurred between a patient and his or her provider as far as the medical care that was provided. These medical records may be referred to in legal proceedings to understand the diagnosis, treatment, and progress of a patient, or they may be used to prove malpractice on the part of a health care provider. Today, hospitals, clinics and other healthcare practices use electronic health records (EHR) for storing patient information, which enables doctors to access the necessary information quickly and easily.Īccurate medical records not only help in ensuring good patient care but also serve as legal documents for healthcare providers as they contain information about adverse events such as accidents, criminal activities and any such act that harmed patients and for which they are under treatment. Information can be stored on computers, hard drives or servers. With the advent of digital technology, storing information is easier than ever before. Patients’ medical records are kept in a secure place, so that they are safe from unwanted access and can be accessed by authorized personnel only. The HIMSS says that, “Regardless of format, whether paper, hybrid, or electronic, the medical record must meet the requirements of the legal and business record for the organization.” Accurate medical records can be generated by transcribing the physician’s dictation with the help of a reliable and experienced medical transcription service provider.Ī medical record or a medical document is the most crucial element of a healthcare organization and an important part of the process of diagnosis and treatment of patients. In the U.S., federal and state laws require that every health care provider establish and maintain an accurate medical record for each patient.
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