Year: 2011
Type: article
Abstract: Objective An extensive amount of time goes into each patient encounter that is unrelated to providing clinical care. This study introduces a new concept that integrates billing/coding, transcription, and patient education through digitally recorded patient encounters. Method In the taped clinical encounter, the history of present illness, past medical history, physical examination, and assessment and plan are recorded. Between each section the clinician provides a summary of the pertinent data collected. The video is then reviewed by a coding expert for billing purposes. Results In carrying out the above in a standardized patient, we successfully eliminated all paperwork and dictation that would be done after leaving a patient’s examination room. A typed transcription of the pertinent patient summary dictated to the camera was entered into the patient’s electronic medical record. A digital record of the encounter was also made available through the electronic medical record that the patient could access from home. This allows the patient to review the diagnosis and treatment plan to improve compliance. Both records were also available to the referring physician to review. Conclusion Through the digital recording of patient encounters, we hope to improve clinical efficiency, coding accuracy, patient compliance, and referring physician gratification.
Source: Otolaryngology
Authors: Theodore R. McRackan, Robert F. Labadie
Language: English
Subfield: Health Information Management
Field: Health Professions
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2050664553