To Whom Were You Speaking, Sir?

Recently a provider dictated, “This patient is on Serevent and Symbicort, and she should not be on both medications.  Is this an electronic medical record error?  I would clarify this."

For this specific client, the Healthcare Documentation Specialist was left guessing as to whom the provider expected to clarify the potential drug error.  There are choices:  The provider prior to affixing his signature?  The HDS with notification to the hospital for clarification/correction?  The nurse possibly caring for the patient who may or may not read the H&P?  The patient?  Each of these options results in an incomplete solution—and an incomplete (or incorrect) medical record—and patient risk. 

This provider’s request is an example of trying to force a square peg in a round hole—utilizing traditional dictation and transcription in an EHR workflow with limited opportunity for correction or validation. 

Opti-Script has solved that workflow challenge with one of its client-partners:  OSS Health in York, PA, a large orthopedic practice.  OSS providers are given flexibility as to their preferred workflow, ranging from traditional transcription to validation, quality assurance, and risk management for front-end SR documents—all completed right in the OSS EHR (Medent).  The experienced Opti-Script HDS would have accessed the patient’s master medication record, verified the meds, and immediately alerted the client team of the discrepancy and risk. 

A collaborative case study covering our work with OSS Health can be found here:  OSS Case Study