Your Documentation Matters

It feels like a no-win situation sometimes. There’s a patient that needs attention, sometimes in emergency conditions, and while you need to do everything you can in that moment to ensure the patient is getting the best care possible, part of ensuring that good medical care continues is the documentation.

It’s not just enough to make sure that a proper prescription is written out, if one is required, the nature of the emergency, the exact details of the illness or injury, all of these bits and pieces of information can make a difference not just for the patient, but for the subsequent doctors and caregivers that may need to administrate treatment further down the line, and the possible financial parties that may be responsible for handling the payment for treatment.

This is where the real dilemma comes in. For example, it might simply be easier to classify an injury as heart failure, but if the actual condition is diastolic, systolic or a combination of the two, those precious seconds used up to not describe the condition precisely could cost $10000 more than the more accurate description of the condition. And this has a gradual effect over the course of a financial year, with the more generic reports ramping up the costs of treatment in the long run.

It’s one of those reasons that no one thinks about until afterwards that make medical scribes a valuable assistant during the treatment process. Now, as a doctor or nurse practitioner, you have more time to assess the condition, and can simply report it to the scribe, who will now take the time that you don’t have to accurately document the situation. Now, going forward, that more medically accurate assessment affects everyone in the later stages of the treatment chain, and it means people can act faster, more efficiently and there’s no need to rediscover things about a particular patient’s case that were already known but simply couldn’t be recorded because there wasn’t enough time.

It’s a given that when it comes time to treat a patient, the most important thing is the patient. Having a medical scribe on hand during the critical first encounter helps facilitate more of this, and leaves that equally important aspect, the documentation to someone else’s full concentration, so you can devote yours to the patient in front of you. It’s just one more of the reasons the Proscribe is committed to providing its services to any and all medical staff who need it.