In my February post, “Can You Hear Me Now?” I shared a list of suggestions for physicians and other dictators to help improve documentation quality. This time around, I am going to focus on the healthcare documentation staff in HIM and transcription. There are many best practices that the healthcare documentation team can implement to assist with dictation and documentation quality, and they all fit into three major categories:
Set expectations
The best way to get the results you want is to spell out what you expect through standards, procedures, and best practices. The healthcare documentation team needs to set the tone for how the organization captures patient information by:
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