Modern physician’s office can be bisected into two parts- the medical practice and the ton of paperwork and documentation that comes with maintaining a health care facility. Even a small heath care center or an individual’s practice has its own share of record maintenance. This is why investing in a credible electronic medical record (EMR) system is necessary.
The main reason for the transition from ICD-9 to ICD-10 was greater documentation precision. However, if the diagnostics is documented by clinicians at a lower level than what ICD-10 supports, it may result in submission of financial claims that are lower. Such documentation will also cause a patient’s medical record to lack details, resulting in incomplete information for future providers.
Information Technology and computers are supposed to make our work easier, faster and accurate. However, the transition to digitized record systems seems to be causing a whole new category of patient safety errors. From ordering medication dosages larger than required to making entries in the wrong patient’s records – are these user errors in the making or are they due to a poor system design?