Is EHR usage overstressing physicians?

‘Doctors have too busy schedule. Before, doctors used to make a hand-written prescription. But since they have to examine so many patients at a time, the handwriting became illegible. This illegible handwriting gave birth to the process of medical transcription where to put down doctor's effort as well as the burden of paperwork, EHR came into focus with its advanced data keeping system. EHR system helps to record patient's data as well as the conversation between a patient and a doctor for improving the quality of treatment as well as to improve the documentation process. But this has been noticed that there are many doctors who do not feel to recommend EHR to their junior doctors. It seems that many doctors are facing trouble with the usage of EHR and this is just because this particular system requires manual input of data where doctors really feel overstressed. Rather than examining patients, they get busy with the documentation process which consumes time and their effort. Doctors get too little time for the documentation process and they have to fill the records format even after coming back home which creates misbalance in their personal life too. It becomes hectic for a doctor to examine so many patients and then fill the records. This becomes so stressful. Of course there are advantages of EHR system like it reduces the burden of paperwork management, quality care and patient's accessibility. But you will be astonished knowing the facts or disadvantages of an EHR system.

Do you know how this EHR system negatively impact upon health professionals? Let’s have a look………

·         Since patients can access all their data like date of admission, health records or history, details of ongoing treatment, medication, details of suspected disease and diagnosis thus these create a panic among the patient. They come back to the doctor and the doctor then has to deal with their panic which really gives stress to a doctor.

·         Patient's data must be recorded with proper privacy and security. But the EHR system is too susceptible to hacking. The malpractitioners or a hacker hack all the data for which information related to patient's data becomes invisible to the doctors, patients and to the hospital management. This creates not only a delay in the entire treatment process but it may also direct a doctor for the wrong treatment. On the emergency situation, it becomes difficult for a doctor to treat a patient when the patient's data is hacked.

·         Each and every time the data must be uploaded in real-time that is immediately after a patient’s visit. Delaying in that process may delay the process of service and service providers may have to rely upon incomplete data. Examining a patient and then at the same time uploading all the details becomes hectic for a doctor as they have to always rush for the next patient.

So, though EHR has a positive impact upon the healthcare services, it is always imperative to know the disadvantages of this system which may potentially interrupt with the healthcare services.

10 must know facts about ICD 10 documentation for medical transcription

The term documentation plays a significant role in the healthcare sector. This can be attributed to the need for properly arranged patient history and the diagnosis data. This  in turn helps in the insurance claims for the patients as well as gaining insight into the patient medical history for pharmacological interventions. The ICD 10 plays a significant role in this aspect in the US healthcare sector. The medical codes that are present can be termed as the “bible” for a medical coder or a transcriber as they form the guidelines for medical coding and transcribing. However the codes that are present are not clear enough and most of the codes does not clearly describe the diagnosis of the patient. This vagueness is thought to be resolved by the shift from ICD 9 to ICD 10. Now for maintaining this ICD 10 codes and working based these coding guidelines it is necessary to keep in mind some important facts-  

1. Laterality forms the core of ICD 10 coding. It is essential that a physician mentions the letrality while coding. The mentioning of the right or left or bilateral clearly helps in easier patient care. 
2. Upgradeable technology is another important aspect of ICD 10  as it enables the patients to have access and use the latest upgraded technology
3. Documenting the period of care is also an essential aspect of the ICD 10 medical coding guidelines
4. ICD 10 involves 50 codes that enables the documentation of disease due to foreign body faster. This helps in better reviewing of the coded medical records and effective holistic care of the patient. 
5. ICD 10 helps a physician in documenting the stage of the disease as well as their seriousness and their chronic nature
6. The medical codes specified by the ICD 10 guidelines enables the transcriber to properly document the anatomical details of the patient for better patient care and diagnosis. 
7.  The coding system being fully digitised enables the users to have full access of the medical facilities and helps the physician's to get the patient data at a go. Thus this helps in providing quality care to the patient. 
8.  In addition to these the ICD 10 documentation guidelines involves the usage of the glasgow coma scale. This scale enables the physician to document the verbal as well as the motor and visual response of the patient. 
9.  The aim of ICD 10 being the resolution of vagueness in coding involves the Gustilo-Anderson scale for describing the types of open fractures and enabling better holistic care for patient.  
10.  Lastly the main essence of ICD 10 medical documentation guidelines lies in the specific definition of the patient condition. Thus it includes the detailed description of Myocardial infarction and its acuteness. 

Thus as a conclusionary remark it can be stated that ICD 10 has well developed features so as to make sure that the patients get quality care along with digitised services. Maintenance of these 10 must known facts will enable the patients as well as the physicians communicate well and resolve critical conditions with easy therapeutic options.