Although healthcare professionals do their best to maintain accurate documentation, mistakes can still happen—that’s just human nature. However, many of these mistakes have life-threatening consequences. Fortunately, this problem can be solved by one thing: accurate medical transcription services that provide a practical approach to minimizing errors in electronic health care records. For organizations that also handle legal documentation, professional legal transcription services can ensure accuracy, compliance, and clarity in all documents.
In this article, you’ll learn:
- How accurate medical transcription services can minimize errors in Electronic Health Records (EHRs) and improve patient care.
- Best practices for maintaining accurate EHRs, including documentation, internal audits, and staff training.
- The importance of HIPAA compliance, medico-legal standards, and the benefits of trial transcription services.
- Additional transcription solutions, including court, deposition, and legal transcription services, are available to ensure accuracy, security, and regulatory compliance.
What Is An Electronic Health Record?
An electronic health record is a digital version of a patient’s medical chart that provides a real-time view of their health information. EHRs go beyond standard clinical data, including patients’ medical history, diagnoses, medications, treatment plans, test results, and more.
These digital copies enable healthcare providers to access and share a patient’s information across multiple healthcare organizations. This allows them to make the most appropriate decisions and smooth workflows while ensuring the patient receives adequate care.
Uses of Electronic Health Records
EHRs are important in their own right; we’ve listed scenarios where these solutions are very much needed.
| Medical Case | Importance of EHRs |
| Patients with chronic conditions | Track long-term treatment, monitor disease progression, and ensure continuity of care. |
| Patients with complex medical histories | Centralized, accessible records of past and current health status for informed decision-making. |
| Patients receiving care from multiple providers | Facilitate communication and coordination among providers, reducing errors and omissions. |
| Emergency and critical care situations | Quick access to medical history, allergies, and medications for informed decisions and timely treatment. |
| Patients undergoing transitions of care | Accurate and efficient transfer of medical information, maintaining continuity of care, and reducing errors. |
To further ensure the accuracy and reliability of your EHRs, Ditto Transcripts offers trial transcription services, allowing healthcare providers to evaluate our precision, turnaround times, and secure handling of sensitive records before fully committing.
Most Common Challenges Associated with EHRs
Now that we’ve covered the practices for producing accurate EHRs, let’s discuss the common challenges related to these systems.
Cost of EHR Systems
Although it may seem unlikely, maintaining an EHR system can financially burden medical organizations. On average, medical practices spend $1,200 per user annually on an EHR system. The initial costs include software licenses, hardware upgrades, and data storage solutions. On the other hand, ongoing expenses include staff training, troubleshooting, and subscription fees for cloud-based EHR solutions—though not all are cloud-based.
As a result, smaller practices with limited budgets may find those costs challenging.
Workflow Inefficiencies
Transitioning to an EHR system can disrupt existing workflows if not implemented properly.
Medical staff accustomed to the “old ways” may spend considerable time documenting information in the EHR. While it may not seem much, it can shorten the time patients spend interacting to understand their needs.
Physicians spend an average of 15.5 hours per week on paperwork and administration, and poorly designed EHR systems can also create additional work. For instance, data may need to be manually re-entered across different platforms, leading to inefficiency, frustration, and reduced productivity.
Security Concerns
As we already know, EHRs are digital repositories of large amounts of patient data, including detailed medical history, medications prescribed, diagnoses, treatment plans, and even billing information.
Breaches of this data and the exposure of information could be used for anything from identity theft to financial damage. In worst-case scenarios, leaked data could even lead to physical harm if a patient’s medical condition is exploited for malicious intent.
Data Compatibility
Some EHR systems are incompatible with those from different vendors, which is a serious setback to seamless communication. In an ideal world, healthcare providers from other organizations should be compatible – at least to the point of being able to share information easily.
However, the lack of standardized data formats or communication protocols between EHR providers can make this challenging. For instance, a specialist may be unable to access a patient’s medical history from another hospital’s EHR system. This can cause delays in diagnosis or even duplicate tests that will only waste resources.
Potential Data Inaccuracy
Maintaining accurate data in EHRs should be an SOP as it is crucial for the patient’s life. However, EHRs can introduce new challenges to data quality. For example, medical staff who are short on time may resort to abbreviations during data entry, which could lead to potential errors.
Poorly designed EHR interfaces require more time to navigate, increasing the risk of data omissions. Inaccurate data in EHRs can have serious consequences for patients, including misdiagnosis, incorrect treatment plans, and compromised patient safety.
Legal Compliance
An EHR implementation must meet specific regulatory requirements, like HIPAA. Consequently, any adjacent services—such as medical transcription, scribing, and deposition transcription services—must follow the same HIPAA guidelines to protect your practice from legal and regulatory penalties.
Best Practices For Accurate Electronic Health Records
If you are a healthcare professional who works with EHR systems, you understand the importance of their accuracy. However, the best practices for producing accurate records aren’t common knowledge within the healthcare industry. So, we’ll take a moment to list them below:
| Category | Key Points |
| Document Every Interaction | Record all patient interactions in the EHR, including presenting complaints, vital signs, physical exams, diagnoses, treatment plans, prescribed medications, and procedures. Accurate documentation supports better decision-making by healthcare professionals. |
| Conduct Regular Internal Audits | Outsourcing to professional transcription providers like Ditto Transcripts improves efficiency, accuracy, and legal compliance while reducing staff workload. We also offer court transcription services to handle legal documentation with the same precision and confidentiality. |
| Use Data Effectively | Validate data entered into EHR systems to ensure accuracy. Accurate data enables reliable reports, analytics, and research outcomes for patient care and healthcare studies. |
| Prevent Excessive Documentation | Focus on the most pertinent details of each patient encounter. Use templates and standardized documentation tools to avoid over-documentation while maintaining accuracy. |
| Get a User-Friendly EHR System | Choose an EHR system that is intuitive, well-designed, and easy to navigate. A user-friendly interface reduces errors and allows staff to focus on accurate data entry. |
| Provide Enough EHR Training | Train staff thoroughly on proper data entry techniques, coding practices, and documentation standards. Regular updates ensure accuracy as system features evolve. |
| Enlist Professional EHR Transcription Services | Outsourcing to professional transcription providers like Ditto Transcripts improves efficiency, accuracy, and legal compliance while reducing staff workload, and we also offer court transcription services to handle legal documentation with the same precision and confidentiality. |
How Ditto Transcripts Can Help You With EHR Challenges
Ditto Transcripts is a premier EHR transcription service provider offering the best medical transcription in the industry at affordable prices. Here’s how we can help with all your EHR woes:
- Time Savings: With Ditto Transcripts, doctors and healthcare professionals no longer need to juggle EHR input and focused note-taking simultaneously. Doctors, nurses, and medical staff can dictate patient information, chart notes, histories, treatment plans, medications, and other relevant EHR data. Audio recordings—captured through dictation apps or other secure methods—are sent to us via our HIPAA-compliant cloud interface. A skilled medical transcriptionist is assigned to transcribe and proofread the recordings. Completed transcripts are delivered in structured formats such as PDFs, RTFs, or other text file types and can be integrated into your EHR system via an HL7 interface for auto-population of appropriate text fields.
- Accuracy: Accuracy is paramount in healthcare documentation. Ditto Transcripts maintains a 99% accuracy rate, employing multi-layered quality checks to ensure every transcript is precise. Even minor errors in patient details can have serious consequences, so our team is trained to handle complex medical terminology and sensitive data with the utmost care. We also offer verbatim transcription services when exact, word-for-word records are required, ensuring no detail is omitted or altered.
- 100% U.S.-Based Human Transcription: All transcription work is completed by native English-speaking professionals based in the U.S. This ensures consistent quality, culturally fluent language, and familiarity with U.S. medical terminology. Our transcriptionists can also provide certified transcripts and, if required, appear in court for deposition or legal transcription matters.
- Experience: Since 2010, our medical transcription team has combined expertise with passion. We have a deep understanding of medical terminology, disease processes, and proper documentation practices. You can be confident that your electronic medical records will contain accurate and comprehensive information.
- Timeliness: We understand the importance of timely access to patient information. Swift transcript turnaround allows for faster chart completion, smoother workflows, and more time focused on patient care. Ditto Transcripts offers quick turnaround, including STAT transcription within 4 hours.
- Medico-Legal and HIPAA Compliance: We prioritize patient data security and regulatory compliance. Ditto Transcripts is 100% HIPAA-compliant, with audit trails, long-term, secure storage, redundant security protocols, advanced user access management, and 256-bit encryption. Our medico-legal expertise ensures your transcripts meet both healthcare and legal documentation standards.
- Customizable Formats: Every healthcare organization has unique needs. We provide customizable templates and transcript formatting that integrate seamlessly with your EHR system, aligning with your workflow preferences and organizational requirements.
- Affordable Solutions: High-quality transcription should not break the bank. Ditto Transcripts offers competitive per-line pricing of 7–14 cents, helping reduce in-house transcription or manual data entry costs while maximizing ROI. Our legal transcription prices will give you a better idea.
- User-Friendly Platform: Our online platform is designed for busy healthcare professionals. It’s simple to use, allowing secure upload of dictation files and easy access to completed reports—all in one convenient location.
- 24/7 Customer Support: We provide round-the-clock customer support to address any concerns or technical issues. Our team is always ready to troubleshoot, answer questions, and guide you through the platform or service. Don’t believe us? Here’s a testimonial:
Reach Out To Us For Accurate Medical Documentation
Eliminate EHR & EMR errors and free up time for patient care with Ditto Transcripts. Our medical transcriptionists deliver 99% accurate transcripts quickly so you can focus on what matters most. We offer HIPAA-compliant solutions at competitive rates. Contact us today!
Ditto Transcripts is a Denver, Colorado-based FINRA, HIPAA, and CJIS-compliant transcription services company that provides fast, accurate, and affordable transcripts for individuals and companies of all sizes. Call (720) 287-3710 today for a free quote.