Medical transcription: Creating quality patient medical records

Accurate and complete documentation of the healthcare process continues to play an important role in the healthcare scenario.  Information extracted from the patient –healthcare professional encounter has implications on various aspects of healthcare including:

• Patient safety
• Coordination and continuity of care
• Billing and insurance purposes 

With the recent mandate regarding the creation of a nationwide electronic healthcare system, the mode of documenting the healthcare process has come into focus. Medical transcription, one of the oldest methods of documenting the care process continues to play a significant role in ensuring accurate, complete and useful documentation. Medical transcription is essentially the process of listening to the dictation of healthcare professionals detailing the patient encounter and transcribing it into text format which can be stored in electronic or paper format.

The ongoing debate about the adoption of EMR/ EHR also involves discussions regarding the continued role of medical transcription in the healthcare documentation scenario. One can justify the continued importance of medical transcription services in the adoption of EMR/ EHR by evaluating the alternative methods of documentation available. Some of the alternative methods of documenting the care process are:

Use of speech recognition software: Speech recognition software has been offered as the solution for prompt documentation of the healthcare encounter. Though documenting the care process using speech recognition software has the advantage of cutting down the turnaround time it affects the accuracy of information captured adversely. Medical transcription companies have stepped into the breach and have started providing editing and proofreading services for transcripts produced by speech recognition software. This ensures that the patient medical record reflects accurate and complete information.

Templated documentation: Use of templated documentation or drop down menus has the advantage of documenting the care process in real time and adoption of EMR/ EHR. However this method has the disadvantage of diluting the focus of the healthcare professional from the patient, decreasing the productivity of the healthcare professional, not capturing the narrative portion of the patient medical record and having no quality checks to validate the information. Medical transcription services have ensured adoption of EMR/ EHR using HL7 interface while still ensuring complete, useful and accurate documentation. Using medical transcription as a method of documenting the care process also has the advantage of allowing the healthcare professional to focus on the patient and improve on his/ her productivity.

Scribes: The use of scribes to document the care process could have the following shortcomings:

1. Privacy and security concerns
2. Lack of training in medical terminology
3. Lack of clarity in documentation
4. Formatting errors

However documenting the care process using the services of a professional and technologically savvy medical transcription company would ensure accurate transcription within the required turnaround time using transcription technology that would provide maximum benefits while still being easy to use, savings on cost of transcription and secure HIPAA and HITECH compliant transcription.

TransDyne, a leader in the outsourced medical transcription industry has used their extensive background in information technology and their experience in serving the needs of the healthcare sector to provide affordable and integrated medical transcription solutions.

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.