Medical Documentation Tips For Pediatricians

 

The emergence of Electronic Health Records (EHRs) has made it much easier to record numerous patient parameters. In order to give their patients the best medical care, pediatricians must maintain accurate and timely medical records. Partnering with a medical transcription service provider that specializes in pediatric transcription is a practical solution.

Pediatric patients are represent a clinical group with a specific set of problems. For instance, respiratory complaints, infectious diseases, and problems with chronic or congenital diseases are the top three causes of pediatric hospital admissions.

When clinicians fail to provide a precise diagnosis, paperwork might become more complicated. Many clinicians are hesitant to label the child with a diagnosis that could follow them throughout their lives or suggest that the child is sicker than they actually are. In this situation, documentation experts can play a significant role in assisting the doctor in creating a diagnosis that is appropriate and correct.

Documentation tips

The format of an evaluation report for a pediatric patient might resemble like other general physical therapy evaluations. It should include the reason for the referral, a description of involvement, activities, and any impairments, an assessment, goals, and treatment plan. However, there are certain crucial factors to take into account while drafting reports and documenting this demographic.

·         Educate parents: Parents of patients should call the pediatrician before going to the emergency department or urgent care. In the end, doing this is better for the health of the patients. They can receive medical guidance from a doctor who is familiar with and sympathetic to them by making the initial contact to their primary care provider. Sometimes, going to different medical specialists can't be avoided. For instance, a patient might break their arm on a day when their primary care provider is unavailable to visit them or they might have a scheduled surgery from a specialist. Parents should be aware of the significance of those visits being recorded, documented and communicated to them in these instances. To solve this problem, the patient’s parents should ask other healthcare professionals to share information about their visits with their primary care physician. By doing this, the primary doctor is informed of any medications the patient is taking or treatments they are receiving from other healthcare professionals, enabling them to give the patient the best care possible.

·         Screen patients prior to consultation: Before each meeting, give your patients a questionnaire to complete. This will speed up the process and increase the precision of the diagnosis. Before each visit, the doctor might ask every patient to complete this online survey. If they don't, they should be asked to fill it out on paper in the waiting area before the consultation. Because of this routine, the physician will be fully aware of patient details before the session. Questions to ask patients include: "Have you seen any other healthcare professionals since our last visit? When and why, if so? "After receiving the patient’s reply, the physician can compare them to the medical records in the PCC’s EHR and make the necessary changes to the patient's information. This benefits both the physician and the patient by providing a more accurate picture of their medical history.

·         Be sure to ask for records from external providers: Pediatricians should ideally have a plan in place for how they wish to get those documents if a patient sees another physician but doesn't have their medical records moved. Having a template for the release of medical records might be useful in these circumstances. The patient's details can be entered on the template and the request faxed to the other provider who saw the patient. However, sometimes this may not be sufficient. The previous pediatrician may not have been diligent  in collecting medical records from this patient, who may have gone to nearby specialists, urgent care centers, or emergency rooms. So pediatricians should inquire about the patient’s previous medical treatment before seeing them. 

To maintain proper medical records and guarantee the appropriate treatment when it is required, accurate, timely transcripts are essential. To produce accurate pediatric medical reports, pediatricians can reach out to a reputable HIPAA-compliant medical transcription service that offers specialized documentation solutions for pediatric care facilities