Medical transcription is the process of creating patient medical records, converting the audio of the patient- healthcare professional encounter into text format. Quality or accuracy of the information in the patient transcript is one of the most important factors, as the information in patient medical records is vital for providing quality care, to start the process of reimbursement and as a component of risk management. To this end while outsourcing medical transcription it is important to assess whether the medical transcription service provider has methods for quality assessment.
As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.
Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.
Do: Assessment policies and procedure
This part is very important as it shows that there is a formal policy, which lays out the procedure for quality assessment. Assessment and improvement procedures should be throughout the documentation process, instead of an exercise used for filling blanks, flagging errors or tabulating error rates.
The purpose of this exercise should be to help provide feedback, play a significant role in ensuring patient safety and maintain integrity of the document.
The assessment policy should include:
- Concurrent review: This means that the transcripts that have gone through the first stage of transcription by the medical transcriptionists, are subject to complete and comprehensive review. This is absolutely essential when the expertise of the medical transcriptionist has not been established or when the medical transcriptionist transcribes for a new specialty or when transcribing for a new healthcare professional.
- Retrospective review: Though concurrent reviews are ideal for the quality process, it may not be possible to review 100% given the tight turnaround time requirements. However reviews are an essential learning tool especially for medical transcriptionists, it is important to have retrospective reviews
- Review of flagged documents: This type of review occurs when the initial or first stage of medical transcription has flagged blanks/ error etc. It is important to review these transcripts and resolve the flagged errors before transmitting for final authentication to the healthcare professional/ healthcare facility.
- Using the findings from these reviews as feedback: The purpose of these reviews is to help improve the quality and reduce errors. Therefore the findings from these reviews are used as a learning tool to improve the work of medical transcriptionists. Another important aspect of these findings is also to provide feedback to healthcare professionals. The findings can be used to educate healthcare professionals in best practices for dictation.
The purpose of reviews is to improve quality, provide feedback, enabling medical transcriptionists to improve quality/ accuracy of the medical transcription.
TransDyne, a leader in the medical transcription industry has a well-established process in place of quality assurance. Each and every document is subject to multiple levels of quality check. Moreover the quality assurance team does random checks of transcripts and the findings are used as learning tools to improve quality
TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!
To avail complete medical transcription services from TransDyne, click here.
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