Each year approximately 7.5 percent of doctors have a malpractice claim filed against them with the largest concentrations in the fields of neuros and cardiac surgeons. Only 1 in 5 cases are successful, but the financial and emotional tolls they can take on a practice are substantial.
EHR systems usually contain a practice specific template that is geared to the specialty and makes it easier for physicians to pull down their most commonly used diagnosis and procedure codes. This allows for the production of a clean encounter or billing sheet and gives the physician the advantage of billing at the highest allowable codes for his services. Upon completion of the electronic dictation, the note is usually sealed and changes are not permitted after electronic signature.
Systems that include features such as Dragon-Speak will allow you more room to include patients with a more complicated history than those that work exclusively with pull down or click menus. Voice recognition systems are much improved than in past years, but it still may take some time to recognize new words or phrases when you use them for the first time.
There are just so many diagnosis and procedure codes that you can program into your system before you start making it profitable and usable, but it is necessary to guard against letting the system dictate what codes you use for your patient's visits. This is especially true to protect yourself in case of a malpractice claim against the practice.
Traditional dictation allows you to pre-program your review of systems while it also give you the opportunity to create a more complete record tailored to your patient's specific symptoms and history. You have room to break away from the boilerplate notes that are often part and parcel of most EHR systems. The EHR notes may be fine for insurance reimbursements where notes are requested, but if you rely on a standard note using only your typical pull down options, you may find yourself coming up short should your practice be subject to a malpractice claim.
You will want to assure that your EHR system allows you to easily input those specific symptoms and histories that are not part of your usual patient routine. A combination of a pull down menu and some dictation program will give your practice the opportunity to create unique notes when they are necessary.
It has recently been decided that EHR records may be used in cases of malpractice defense and these notes will be as carefully scrutinized as those that were handwritten several years ago. The EHR system also may make your practice prey to unfinished notes that may remain incomplete unless you have a good checks and balance system in place. You may be able to produce a viable encounter with just the basic input, but your note may not be good enough to provide you with a good defense in a malpractice case.
You should view your EHR system as an ongoing creation and it may be wise to make a careful analysis of your patient notes every ninety days to make sure that you are not carbon copying note after note regardless of patient presentation. Assure yourself that you are in charge of the finished product and that you are satisfied with the result. In our old system of dictation, the physician was required to think about his description of each particular patient and to use his thoughts to create an effective record. Let's not rely on the built in technology of EHR to organize and create our thoughts for us.
We will be dealing with a more savvy patient population in the future and we will want to assure that we do not fall prey to damage that originates from our systems, despite our goal of excellence in medical care.
EHR systems usually contain a practice specific template that is geared to the specialty and makes it easier for physicians to pull down their most commonly used diagnosis and procedure codes. This allows for the production of a clean encounter or billing sheet and gives the physician the advantage of billing at the highest allowable codes for his services. Upon completion of the electronic dictation, the note is usually sealed and changes are not permitted after electronic signature.
Systems that include features such as Dragon-Speak will allow you more room to include patients with a more complicated history than those that work exclusively with pull down or click menus. Voice recognition systems are much improved than in past years, but it still may take some time to recognize new words or phrases when you use them for the first time.
There are just so many diagnosis and procedure codes that you can program into your system before you start making it profitable and usable, but it is necessary to guard against letting the system dictate what codes you use for your patient's visits. This is especially true to protect yourself in case of a malpractice claim against the practice.
Traditional dictation allows you to pre-program your review of systems while it also give you the opportunity to create a more complete record tailored to your patient's specific symptoms and history. You have room to break away from the boilerplate notes that are often part and parcel of most EHR systems. The EHR notes may be fine for insurance reimbursements where notes are requested, but if you rely on a standard note using only your typical pull down options, you may find yourself coming up short should your practice be subject to a malpractice claim.
You will want to assure that your EHR system allows you to easily input those specific symptoms and histories that are not part of your usual patient routine. A combination of a pull down menu and some dictation program will give your practice the opportunity to create unique notes when they are necessary.
It has recently been decided that EHR records may be used in cases of malpractice defense and these notes will be as carefully scrutinized as those that were handwritten several years ago. The EHR system also may make your practice prey to unfinished notes that may remain incomplete unless you have a good checks and balance system in place. You may be able to produce a viable encounter with just the basic input, but your note may not be good enough to provide you with a good defense in a malpractice case.
You should view your EHR system as an ongoing creation and it may be wise to make a careful analysis of your patient notes every ninety days to make sure that you are not carbon copying note after note regardless of patient presentation. Assure yourself that you are in charge of the finished product and that you are satisfied with the result. In our old system of dictation, the physician was required to think about his description of each particular patient and to use his thoughts to create an effective record. Let's not rely on the built in technology of EHR to organize and create our thoughts for us.
We will be dealing with a more savvy patient population in the future and we will want to assure that we do not fall prey to damage that originates from our systems, despite our goal of excellence in medical care.
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