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Physician Partners in Clinical Documentation
Accurate and complete clinical documentation is vitally important in delivering quality patient care. Healthcare documentation specialists partner with physicians to perform many functions to assist in clinical documentation in the EHR. Our skills and experience align us perfectly to: 
  1. Transcribe dictation into the EHR, or other integrated systems, on behalf of the physician.
  2. Review and edit documentation created via speech recognition technology. 
  3. Record content in the EHR in real-time as a scribe on behalf of the physician.
  4. Perform quality assessment reviews of documents to ensure accuracy and completeness.
  5. Develop and implement EHR documentation policies, procedures, and best practices to comply with regulatory requirements.
  6. Create EHR templates to assist physicians with more efficient content capture.
  7. Train and provide ongoing support to EHR users on document creation workflow and speech recognition functions.
  8. Engage in ongoing communication and collaboration with medical staff regarding EHR documentation issues.
  9. Utilize the EHR in assembling and analyzing medical documentation to improve patient care, compliance, safety, and reimbursement.
  10. Monitor and report results of compliance and ethics assessments (e.g., as per HIPAA) performed on EHR documentation.

Registered and Certified Healthcare Documentation Specialists

Healthcare documentation specialists, also known as medical transcriptionists, understand medical language, clinical practice, data integrity, and the basics of health information technology, with credentials attesting to that expertise. Their body of knowledge is vast and includes pharmacology, human disease processes, anatomy and physiology, and diverse technologies used to capture health data. Healthcare documentation specialists partner with physicians in clinical documentation given their understanding of the requirements of HIPAA, documentation workflow, and HIM processes. 


Resources for Hiring Healthcare Documentation Specialists

Model Job Descriptions

Compensation Best Practices

Documentation Style & Standards

Quality Assurance Best Practices for Healthcare Documentation Specialists

Quality Assurance Best Practices for Clinician-Created Documentation


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