Do’s and Don’ts of Maintaining Good Clinical Records

The handling of clinical records is strictly governed by the law in most countries. Clinical documentation is required to ensure proper patient care. It is also necessary to ensure that clinical records are kept confidential because they are strictly personal. In this blog, we will delve into the aspects that medical transcription services in Australia look into while maintaining clinical records.

• Accuracy of the content

According to medical council guidelines, it is deemed important that it be clear, accurate, legible, and written in a scientific manner. Medical transcriptionists need to be very particular about including all the clinical findings. To be admissible in a court of law, the clinical records should mention all the medical decisions, treatments or procedures done.

• Seamless integration with the EHR or EMR system

Blending a medical transcription service within the EHR system of a setup is required. Professional medical transcriptionist service will be able to use the existing EHR or EMR system of a healthcare setup. This will not necessitate a complete overhaul of the EHR or EMR system.

• Pay attention to all the details.

Medical transcriptionists are professionals who will pay attention to minute details. Patient outcomes will depend on maintaining a systematic record. Since physicians are busy taking care of the patients, medical transcriptions have to maintain the clinical records meticulously. They will categorize the lengthy paperwork into various components like history, patient examination, differential diagnosis, treatment, follow-up, and progress.

• Confidentiality and data protection

Medical transcription services in Australia should be aware of the HIPAA requirements that need to be followed. This will ensure the privacy and security of the patient’s personal information.

• Quick turnaround time

Physicians are busy diagnosing patients. By hiring medical scribes, physicians can be given extra time to take care of the patients. A quick turnaround time will also help in treating ailments like cancer that spread really fast.

• Provide a human touch to medical transcription.

Many medical transcription companies rely on voice recognition systems that use artificial intelligence. The knowledge that a medical scribe is involved in clinical documentation is reassuring for physicians.

• Consistency in documentation

In order for an EHR system to be consistent, the records must be clear and easy to understand. The EHR system of a healthcare setup will not suffer when medical transcription services are hired in Australia. Medical scribes know about the technical jargon that is used in medical practice, thereby reducing any chances of misinterpretation.