Writing patient record notes
Writing patient record notes is one of the most essential aspects of working as a healthcare professional. With the introduction of new technology into the healthcare industry, particularly electronic health record (EHR) systems, many practitioners have begun to streamline their documentation process. However, there are still a significant number of practitioners who prefer the traditional method of manually writing medical notes. We understand that people have their preferences, and whilst this method may be what you’re used to, it is highly inefficient. Regardless of the field of healthcare that you work in, the development of new technology is allowing practitioners to save significant amounts of time previously spent handwriting their notes. Medical voice recognition software allows practitioners to speak into a computer or mobile device, and the system automatically transcribes what they are saying into a clinical document format. The benefits of utilizing this type of software are significant, and Reaction Data reported that over 60% of doctors currently use medical voice recognition.
Writing medical notes manually: Top 5 disadvantages
Although we understand that implementing new types of technology into an already operating system is daunting, there are way too many advantages associated with medical voice recognition software for it to be overlooked. Additionally, there are certain disadvantages to be made aware of, that indicates the importance of adopting medical dictation software to avoid manual writing.
- Cost: Producing and maintaining medical notes that have been written manually costs healthcare practices a lot more than electronic notes. Not only do businesses have to factor in the costs of paper and copying supplies and storage facilities, but administrative staff need to be hired to manage the distribution and organization of notes.
- Accessibility: Medical notes are commonly shared between different healthcare providers, insurance companies, family members, and lawyers. As such, it is critical that they are easily accessible to authorized users. Even if your handwritten notes have been organized effectively, it still takes time to access and retrieve them. Notes that are stored electronically can be accessed by authorized users 24/7, which facilitates better continuity of care and effective communication.
- Quality: One of the most important aspects of a medical note is that they are accurate. Regardless of how experienced you are as a healthcare worker, humans will inevitably make mistakes and errors, and whilst it is not the end of the world, it significantly reduces the quality of notes. Furthermore, the actual physical copy of a handwritten note is at risk of being damaged; paper is fragile and can be easily ripped or stained.
- Reduced productivity: Elevating the productivity of a healthcare practice should always be a priority, as it means a greater number of patients in need will be able to be treated. Handwriting clinical notes take up a lot of time, and if there is an opportunity for this process to be streamlined, you should take advantage of it.
- Fragmentation: A patient’s medical records are made up of notes from various encounters with different healthcare providers. It is important for all of a patient’s medical information to exist within the same place so that a provider can treat them accurately. However, chasing down the different parts of a medical record if they have been stored in separate facilities is complicated and difficult. Not having a centralized storage database where all of a patient’s records are kept can lead to poor communication and ineffective treatment.
Time spent in writing manual medical records
The administrative tasks that practitioners are required to complete, including clinical documentation, take up so much time that doctors are often unable to see the number of patients that require care. The recent increase in patient numbers reflects a healthcare industry that is overwhelmed and understaffed, and it has become more important now than ever to implement streamlined methods. In fact, one report found that doctors spend 49.2% of their time doing paperwork; a horrifying statistic when you consider the fact that there are patients on waiting lists who require urgent care.
Adopting a medical dictation software to avoid lost time in writing manual notes
Evidently, handwriting medical notes lead to a massive waste of practitioners’ time. With medical dictation software, physicians can save a significant portion of this time, which can be redirected to more urgent tasks, including seeing patients. Although the actual software of medical dictation is fairly complex, its implementation and usage by practitioners are highly intuitive. The installation process doesn’t take very long, and good software will integrate into the other systems that your practice already has in place. This means that from the very beginning, all of your medical dictation will be uploaded immediately into the EHR.
Typically, medical dictation software works by a practitioner speaking into their computer, smartphone, or tablet, and the algorithm translates this into a word-for-word text. Depending on the specific software that you use, sometimes AI scribes can alter the text, removing filler words and small talk. This allows practitioners to simply record a conversation with a patient or other individual, and the algorithm extracts the necessary information. After transcribing the note, it is consequently stored directly onto the EHR, creating a centralized database for all of a patient’s notes.
There are various advantages associated with using medical dictation software, the most significant one being the time it saves. Not only will the amount of time spent writing notes be reduced, but it is also far easier to access and store your documents. Additionally, medical dictation software allows practitioners to update and even create their notes on the go, particularly if the system works on smartphones. The increase in healthcare practitioners working remotely means that mobile work is necessary, a feature enabled by voice medical dictation software.
Take home message
Medical speech-to-text software allows practitioners to streamline the clinical note-taking process whilst still ensuring their records are accurate. Whilst we understand that practitioners have their own personal preferences in regards to how they work, the disadvantages that are associated with manually writing notes should not be overlooked. Now that sophisticated yet simple technology like medical dictation software has been developed, it is the responsibility of healthcare practitioners to take full advantage of it. Introducing dictation software will not only save time for practitioners and increase the efficiency of a clinic, but it allows for a greater number of patients to be seen and treated. Ultimately, the benefits associated with dictation software far outweigh any type of disadvantage and it is greatly recommended that you make this transition.