Medical transcription and clinical documentation

The nation is poised on the verge of major change in the way healthcare encounters are documented and shared. The proposed move towards a nationwide electronic healthcare system has lead to a detailed review of the role of medical transcription in this process. This has resulted in medical transcription services being redefined as services that extend beyond mere typing services to that of being an integral part of clinical documentation.

The redefinition of medical transcription services as clinical documentation is further emphasized by the role medical transcription plays in meeting the criteria for clinical documentation.

The criteria for clinical documentation that are met with by medical transcription services are:

Creation of legible records: One of the main criteria of clinical documentation is the creation of legible records. Medical transcription companies ensure creation of neat, legible records in prescribed formats/ templates.

Complete documentation of patient encounter: Clinical documentation advocates the capture of complete information regarding the patient encounter to enable usage for all purposes. Medical transcription not only ensures that the dry facts of the patient encounter are captured but also ensures that the narrative portion of the patient encounter is also documented. This ensures that healthcare professionals and support staff have access to the entire diagnostic and thought process of the healthcare professional during the encounter even at a later date, providing a clear picture.

Clarity of information captured: Information apart from being complete and legible needs to be clear. Medical transcription companies ensure that the information in patient medical records is laid out in a clear manner for quick access and easy understanding.

Consistently defined information: The consistency of the facts of the patient encounter needs to be checked to ensure minimum errors. Medical transcription companies ensure that the consistency of information is checked by putting each transcript through multiple levels of quality checking using well-trained medical transcriptionists and proofreaders

Precise data: The data in the patient medical record needs to be transformed into useful information after eliminating all the “noise” to ensure precision. Medical transcription services ensure this using the right team of medical transcriptionists who subject each transcript to strict quality checks

Reliable: The data in the patient medical record needs to be reliable to ensure correct treatment, coding & billing and for risk management aspects. Medical transcription companies ensure this using the right combination of teams, processes and technology

Timely: Timely information is essential for efficiency and medical transcription companies ensure turnaround time using a judicious combination of technology and teams. Most medical transcription companies even offer flexible turnaround time options to ensure that the needs of healthcare professionals are met with.

It is important for patient medical records to contain information that meets the needs of all the participants in the healthcare service process. This includes healthcare professionals, support staff, patients, health plans, and governmental and accrediting agencies. Outsourcing medical transcription ensures this by meeting all the criteria of clinical documentation and also ensuring HIPAA & HITECH compliance and substantial reduction in costs.

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.