History & Physical (H &P) Notes Transcription Services
Numina Transcription Services, Inc. has been offering timely and meticulous medical transcription solutions to all types of health care facilities and medical professionals dealing in different specialties. We combine the most modern technology with our qualified transcriptionists’ profound skills for delivering accurate history and physical (H & P) transcription solutions.
What Makes Numinatrans Stand Out
Numinatrans is the pioneer in technology and health care performance management. We focus on health information technology related services and have facilitated numerous health care organizations spread across the world to deliver discernible outcomes. Our accurate H & P Notes transcription solutions have helped several physicians and medical practices in enhancing their productivity while improving their efficiency.
Significant Role of H & P Notes Transcription
The treating physician conducts a thorough physical examination and checks the patients’ history every time individuals are admitted to a medical practice. The physician then dictates his patient report that includes details such as patient medical history, reason for admission, past medication and surgeries, if any, and presents symptoms and medication, among other vital things.
This report, having the critical patient information, is crucial in the future course of treatment. Playing an instrumental role in the patient’s health care, H P notes need to be transcribed in an accurate and reliable manner. Here’s where the need for an efficient and qualified medical transcriptionist is strongly felt.
Highlights of History & Physical Notes Transcription Service by Numinatrans
Over 99% accuracy
HIPAA compliance
Reliable customer service and support
Flexible TAT
Reasonable pricing
Consummate processes and need-based skills
Numinatrans has gained experience by providing relentless transcription services to clients from varied medical fields. We understand the importance of H & P notes; we ensure that our solutions are not only accurate but also timely, so that our clients are able to provide the best medical care to their patients.
Medical practices and physicians who are seeking assistance in their patient report documentation may approach us. Logon to our website www.numinatrans.com for further details.
Major Health Care Documentation Errors and Their Prevention
Errors in clinical documentation and incomplete medical records have been among the top reasons for restricting the number of hours for which resident physicians are permitted to work. To be able to provide the most optimal care and achieve patient safety, physicians and medical practices require full and up-to-date medical histories and other patient information. Clinical documentation plays a crucial role in the health care management of individuals.
What Makes Clinical Documentation Vital?
Erroneous medical records are one of the major reasons for patients’ death the world over. Incomplete or unclear medical records may lead physicians and other medical professionals to arrive at wrong decisions about treatment plans and procedures. Patients’ safety relies on their health information documentation to a large extent. Errors in documentation may prove disastrous.
In addition to being one of the driving factors that assist medical practices and physicians in efficiently managing patients’ health, clinical documentation plays a significant role in a medical facility’s financial setting as well. Payers, external auditors, and Medicare audit contractors who are expected to scrutinize insurance claims need to verify medical record documentation as it proves to be proof of quality indicators and medical necessity.
Frequent Medical Documentation Errors
The best route to prevent documentation disaster is through identification of the common errors and having procedures in place for stopping them. As derived by health information management experts, the following are the frequent documentation mistakes that crop up in the health care industry:
Missing or incomplete documentation
Misplaced medical documentation
Misuse of copy and paste functions in health information systems such as EMR
Errors cropping up because of illegible handwriting or misunderstood dictation
Failure to document omitted treatments or medications
New medical conditions or symptoms not being documented
Information being entered into the wrong charts
Duplication of data
Blank spaces in forms inside the records
Remedies for Common Errors in Documentation
Avoid shortcuts such as copy and paste in electronic records system
Make sure that you are charting on the right record
Avoid documentation delay – record details as soon as an action is taken
Use of vague terms such as ‘normal’ and ‘fair’ must be avoided – being specific and concise is suggested
Try to use the patient’s own words and gestures as far as possible – this helps describe things factually
Documenting treatments and medications before they are completed or administered must be avoided
When you come across mistakes, take sincere efforts to correct them promptly
Numinatrans has been offering reliable and meticulous medical transcription solutions to global medical practices. We have a satisfied client base distributed across the world. Physicians and health care facilities may approach us for accurate clinical documentation solutions. For more details, you are welcome to visit our website www.numinatrans.com