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Excellent Tips for Efficient Medical Documentation

Governments give priority to quality healthcare delivery by training medical practitioners and providing the necessary healthcare infrastructure. As a private medical practitioner, it is imperative that you have an efficient system of documenting the medical records. Do not underestimate the power of efficient medical documentation in your practice and that means that you should improve it. Today, most of the doctors spend a significant amount of their working hours entering data into the 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. Here are some of the ideas and ways for efficient medical documentation.

The most useful tip to employ is delegating the data entry role. As mentioned earlier, data entry can consume a significant amount of your time hence you should consider reassigning the time-consuming task. 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. In most cases, medical doctors opt for a medical scribe, but this can be costly. The other means to improve efficiency in medical documentation is using dictation software. However, you will have to create some time to summarize and edit the notes transcribed by the software.

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. 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. Through the optimization of medical billing, all the necessary information will be captured. To ensure that you focus on a single task all the time, you should create a time schedule.

The last tip to consider is the 2-minute rule. Once you reassign some of the documentation tasks that consume your time and adopt a time schedule, you should consider adopting the 2-minute rule. Using the 2-minute rule, you will get to reduce your workload as you will take care of the tasks that take less than 2 minutes immediately. Also, you should consider breaking down the large daunting tasks into small ones.

Therefore, as a medical practitioner, you should consider the above-discussed ideas and tips if you want to boost the efficiency of your documentation process.
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