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
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