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Tag: EMR transcription
April 12, 2019

What Is IME Transcription? Some DO’s and DON’Ts Of an IME Report


IME Transcription stands for Independent Medical Evolution transcription. It is a comprehensive review of the medical report of a patient performed by a doctor not earlier involved in the patient’s care.
     It is usually performed for a legal purpose, such as evaluating eligibility for the worker’s compensation or benefits or disability benefits related to an accident or an injury. The qualified medical evolution is the same thing as an IME.

IME transcription covers the following topics:
– Entire description of the patient’s medical treatment including a full review of available records,
– Physical examination,
– Consider the additional report reported by the private investigator,

– Determining as to whether the patient is going through the permanent disability or it’s nature and degree.

The format of IME report is very different than any other report type. It becomes very essential to obtain a model report or template to use as a starting point, even though the sections dictated may vary.
If we talk in brief that what is the exact process through which it goes. It includes the following sections:
1) Introduction:
The first that an IME does is to mention the full name of the patient, the exact date of injury or the onset of the report, and the purpose of the report. If it is related to any insurance or disability claim, a case number is given.
Re: Patient, Unfortunate
DOB: DD/MM/YEAR
Case#: 12345678
Date of Injury: DD/MM/YEAR
Date of Checkup: DD/MM/YEAR
The first paragraph of the report compiles the purpose of the report.
2) History and Current Complaints:
The case history can be given in the single large section titled history or be classified in the subheadings. It provides detail about who the patient is and how he reached to be in his current situation. If the injury is employment related, it will definitely include the work history going back for years.
   There are many subheading used in the history portion including past medical and surgical history, family history, and social habits. Each and every encounter with the medical transcription provider may be listed by date and time.
 When the compensation is sought for the disability, a great deal of attention is focused on the patient’s physical and mental capabilities before and after the incident.
Almost anything can be included, if the requestor hired a private investigator to follow the patient around the watch.
If anyone has the slightest doubt about a word or phrase, can flag it for the dictator review.

3) Physical Findings:
IME is purely based on the review of the records, but many times  there’s an in-person examination as well. This exam is limited to body parts/systems related to the reason for IME but can go on to detail, resulting like Hand grip strength, circumferential measurements of both upper extremities showed left arm, left forearm, right arm, and right forearm.

4) Diagnostic Studies:
The examiner reviews and comments on the results of laboratory tests, MRIs, and other diagnostic studies. This discussion may be under such kinds of headings or also can be incorporated into another section.

5) Medical Records Review:
An IME often includes the documents that the examiner reviews as a part of the evaluation. Such documents contains the reports from workplace visit, treatments, and diagnostic procedures the
patient received. The record list may be dictated near the starting of the report as part of the introduction or just before the examiner renders the conclusion.

Conclusion:
This is the place where IME reports get widely divergent. The resulting conclusion consist one of three formats.
– Simple Yes/No
– A series of answers to specific questions
– A series of subheading related to rating degree of disability.

Physician Certification:
A report that is especially created for the legal use often conclude with a physician certification. It consists of a few lines that explains the examiner’s credentials, followed by a place for the examiner to date and sign the report and attest to its accuracy. It can be added to the document after the transcription or as part of the transcription.

An Independent Medical Evaluation (IME) reports doesn’t come only with a lot of pressure, it also requires meticulousness. While we want to serve our clients. it’s never a good idea to sacrifice the integrity of your IME report by making mistakes.



Here are some of the DO’s and DON’Ts of a good IME Transcription report.
5 DO’s Of A Good IME Report:
1)Make Your Report concise and uncomplicated:
While you feel yourself dealing with a very complicated situation, your report must remain clear in all aspects. Keep your words always clear, and your conclusion brief.

Doing IME Transcription WIth Mobile

2) Define Terms properly for Non-Medical Personnel
The IME report contains so many typical and technical words used in medical, shorthand, abbreviations etc. When you don’t find the simpler words for such kinds of words, you should define them at the first time. It will all help to make your report more clear and accessible.

3) Focus on Quality over All:
The most important thing, in the client servicing, is customer satisfaction. You should start from a professional IME templates to make it easier to create consistent, high-quality reports.

4) Back Up Your Statements With Facts and Documentations:
Many times, everyone is not able to understand some of the information you present. To avoid ambiguity and misunderstandings, you should always include the supporting documents.


5) Strive For A Measured and Objective Tone:
Keep your report out from emotion or aggressive language. If your report veers into that kind of languages, readers will view it as biased and it won’t be a good sign for your business.

5 DON’Ts Of A Good IME Transcription Report:
1) Do Not Sacrifice Your Credibility:
If IME transcription brings a good source of income for you, it’s very essential you remain credible and professional with reporting. Clear and concise language makes it easier for the transcriptionists to finish the job with no errors in the copy.

2) Don’t Use Absolutes Or Contradictions In Report:
If an examiner makes an easy mistake to pepper their statement with absolutes. You should only use absolute phrase at that place where there is only one answer. Rarely is something applicable to all people at all times.
 This also applies to contradictions. You may think to do it to add some clarity, but it only adds confusion. If anyone finds just one example where your absolute statement isn’t so absolute, it can invalidate your statement altogether.

3) Don’t Add Any Kind Of Prejudice in Your Report:
The IME report should not contain any types of non-medical opinions or personal feelings on the situation. It should not show your own belief or lifestyle. You must remain impartial in each and every way.


4) Don’t Add Anything Extra To Your Report:
The independent medical examination serves a purpose. Don’t deviate from the topic. Always keep yourself focused. Never try add in irrelevant data from unrelated things.

5) Don’t Use Uncertain, Vague, Ambiguous terms:
The IME report must show the confidence. You should avoid the statement that sounds like you are making a guess. Always try to keep your report states what is and what’s known. Your report should not contain statements that contain uncertainty.

You can always contact Eyered Transcription for EMR Transcription and all types of transcriptions for the transparent and satisfactory services. We have been doing this for 20 years and we have more than 100 satisfied clients. You are always welcome here with your every types of queries through our email or call.




By: Anna williams Category: blog
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April 8, 2019

The Need to use transcription with EMR system

EMR Transcription consists of transferring the physical, written medical records of patients on a digital medium. Doctors use paper, as usual, or dicta phone at the place of place in recording the condition and treatment of the patient. After that these records are transferred to a digital, usually computerized format, by an EMR medical transcription company. These records are also stored on computers instead of on paper and in files.
             
There are so many reasons that we need to use transcription with EMR system. As the healthcare industry is growing, the healthcare practices are implementing Electronic Medical Records (EMR). If the medical transcription industry is eliminated tomorrow for good. The medical professionals can discover your transcription through your EMR system. It will obviously boost the productivity, accuracy and many more beneficial things.


Here are the following reasons that a practice should use transcription with the EMR system.


1) It Increase Productivity And Saves Time Too:
EMR system allows the physician to maintain their productivity rate. The schedules of the physicians are obviously very busy, as they should be – overall they are the primary source of earning in the clinic. Having physicians’ type patient notes into an EMR system would waste of their valuable time, and will also lead to them seeing fewer patients. So, Using of EMR system can definitely bring the changes the productivity of the physicians.
2) Increases The Accuracy Level:
As we all know physicians prescribe very fast and very rough. Physicians types notes can lead to high type of error rates. The physicians are often multi-tasking or rushing from one appointment to another appointment, so the quality and thoroughness can be compromised. The quality and quantity can’t be maintained at the same time. But the medical transcriptionist do a quality check of the report and have a 99% of accuracy rate. Whereas many physicians complain of copy -paste or copy forward function on EMR, that can lead to the wrong information being stored in the patient’s system.

3) Reduces The Extra Cost Of Data-Entry:
Physicians are too valuable of a resource to be used for a data-entry task. Recruiting a medical transcriptionist in the premise can cost of so many things like salary and benefits. The voice recognition systems are very costly and have been showing higher error rate than a human medical transcriptionist. By using medical transcription services, practises will reduce the overall operating cost, and most even find their reports are done faster and with fewer errors.

4) Revenue Maintenance:
Typing notes for each and every patient slows doctors down and leads to  them seeing fewer patients than expected. Seeing fewer patients will definitely decrease the revenue of the clinic or the hospital. By including the dictation techniques in their medical practises, physicians can see many more patients  daily basis that will definitely make an increment the revenue of the clinic. So by using dictation, raise the revenue of your healthcare or of your clinic.

5)Helps in Enhancing Usability and Making Useful Notes:
By using EMR system, the transcription has become easy for a doctor to tell the whole story of a patient at one time at one place. Transcription with EMR system allows a physician to tell the complete story of a particular patient than worrying about template fillings, generalized drops downs. Telling the complete with EMR with dictation will clarify the patient’s record and it definitely leads to a proper chart that can be easily used for the medical billing personnel.


A doctor prescribing

Why Choose EMR Transcription Services From Eyered TRanscription?
If you choose offsite EMT transcription services from Eyered Transcription, you can get enough time to focus on patient care instead of administrative functions that involve code keying and terminologies into EMR transcription. Our smooth EMR transcription service will bring you more per dollar. Get cheaper, faster and better solution tailored for your requirement and budget size.


Here are the reasons why you should choose Eyered Transcription for EMR Transcription Services:
Certified EMR Transcription Provider:
Eyered Transcription is a HIPPA-compliant and ISO certified EMR transcription services provider offer services that fully goes with regulatory compliance of the industry.

Experienced And Passionate Team Of Transcriber:
Eyered Transcription has a very experienced and passionate team of transcribers who has been doing EMR transcription services for 20 years for various types of transcription projects. Our team is well aware of all the coding systems like ICD-10, ICD-11 to discharge the service in a risk-free manner.

Cheap Pricing Options:
Our wide range of services will let you save up to 30 to 40% in cost because we value our clients. We only and only charge 7 cents per line that is below the average in the transcription industry.

Turnaround:
You can save your precious time to partner with us. By a whopping 50%, you can lower your TAT. It will allow you to focus on the more aspects of the treatment and patient care.
EMR Transcription Services We Offer:
When a clinic or practice outsource the EMR Transcription. The team of EMR transcriptionists of Eyered Transcription carries out EMR services from inception to completion in the quicker and accurate manner. The professionals who perform EMR documentation of patient encounters using handheld audio recorders can send dictated recording by uploading the same on our server.
After converting EHR transcription into written documents. We notify you through email. By securely logging into our system, you can easily and securely download the electronic medical records.

By: Anna williams Category: blog
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