Challenges in Healthcare Documentation

Challenges in Healthcare Documentation

Healthcare documentation (medical transcription) is one of the most critical processes in the healthcare industry that provides the basis for physician follow-up, decision making of the physicians and the processes of medical coding and medical billing. The medical coding process assigns different codes to the services provided and procedures performed taking the transcription reports as the source. Based on these codes, the medical billers generate bills and submit claims to the insurance companies to get reimbursements. Such an important process of the healthcare industry faces a lot of challenges that need to be understood by the people in healthcare documentation jobs.

  • Data errors: Irrespective of the size of the healthcare facility, errors while inputting the data can happen in any organization. Accurate record-keeping is vital for every organization but, facilities that employ speech-recognition software to record their dictations depend on their staff for inputting dictation records into the EHRs which can result in wrong information being keyed-in during busy office hours. To avoid such errors and maintain accurate records of the patient data, it is advisable that facilities that do not have in-house transcriptionists should outsource this process.
  • Complexity in the documentation: The healthcare documentation specialists face challenges due to the complex procedures followed by the healthcare facilities. Different healthcare facilities use different kinds of EHR systems or speech recognition software that make it difficult for the transcriptionists to transcribe or edit the reports leading to the consumption of more time to fix the issues arising from this challenge.
  • Technology issues: Healthcare documentation companies use either word processing documents or online software to transcribe the audio files into reports. When technology is used, there are possibilities of errors due to software that is not updated or loss of network connectivity.

A healthcare facility’s practice should not suffer due to healthcare documentation challenges. Although these kinds of challenges are faced by many healthcare facilities, it is required that they avoid or minimize these by adopting certain measures. Here are some ways a facility can overcome these challenges.

  • Updated software: Healthcare facilities should ensure that the software they are using is the updated one with the current version of the software and free of any glitches. Transcriptionists can work with ease and flawlessly when they have the right tools for spell checking, speech correction, and other online resources.
  • Outsourcing: This is one of the best ways to defeat the risk of errors that are bound to arise due to the pressure faced by the staff of the healthcare facility. Outsourcing the process of documentation to the healthcare documentation companies that have experienced and well-trained staff will reduce the burden on the staff of the facility which helps them focus on their core job.

There will always be issues or challenges that healthcare facilities have to face during various processes. A facility’s goal should be to identify the various challenges and take appropriate and timely measures to tackle them. Choose the best healthcare documentation companies and minimize the challenges of the documentation process.

Challenges in Healthcare Documentation
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