Structured transcription

Structured transcription can be defined as medical transcription that is done within strictly acceptable standards that define medical transcription. The standards of medical transcription can be defined by accuracy, turnaround time and security along with the added benefits of using easy to use technology and being reasonably priced. Moreover healthcare is a vast field consisting of various specialties with the language and terminology of each being specific to that specialty.

Structured transcription services would include having a knowledge what the transcription for each specialty would involve and provide quality transcription in the format required for that specialty.  Structured transcription services ensure that the medical transcriptionists working on the transcription are well versed with the language, the terminologies, the report formats, drugs and procedures associated with the specialty. This would also require the transcription team to be kept constantly updated on the latest developments in the field, as medicine is a dynamic field with new developments and discoveries

Some of the types of reports that are created by medical transcriptionists are as follows:

Patient History and physical examination report: This contains a brief about the patient name, age, gender, occupation, family health history, habits like smoking etc. and the details of the physical examination.

Consultation report: This contains the details of the findings by the consultant to whom the patient has been referred to for further treatment or diagnosis depending on the symptoms

Operative report: This contains the details of the operation/surgery that a patient has undergone including details of the procedure, duration, the anesthesia given etc. This may also contains some postoperative details.

Radiology report: This contains details of the radiologists’ findings on the X-rays, MRI scan, Ct scan, nuclear medicine, fluoroscopic studies etc along with the reports.

Pathology report: This contains the findings of a pathologist of the tissue sample.

Laboratory report: This contains the laboratory findings on body fluids

Emergency report: This is a summary of the patient’s visit to the emergency room for emergency care.

SOAP note report: This contains

• Subjective: This section contains patient’s current condition like age, gender, and pertinent symptoms etc.
• Objective: This section contains vital signs, findings from physical exams. Lab test results, co morbidity etc.
• Assessment: This contains quick summary of symptoms and diagnosis etc.
• Plan: This contains treatment plans, document goals for the patient with reasonable time lines etc.

Progress note report: This contains progress of the patient after treatment/ operation/ procedure etc.

Therapy report: This contains details of the therapy given to the patient

Discharge summary: This contains all the details, which are generated when the patient is discharged including the treatment given, the progress of the patient, any reports and findings etc.

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 understands that the needs of each specialty of medicine are unique. Therefore the transcription requirements of each specialty are different. Knowing this and the importance of creating accurate and timely records, TransDyne has created a unique training program for its medical transcriptionists. Under this program medical transcriptionists are trained to become expert transcriptionists in one or two specialties of medicine.

The structured transcription services offered by TransDyne are an important step towards adoption of EMR/ EHR using HL7 interface, so that discrete data elements can easily be parsed into the relevant areas.

TransDyne offers structured transcription services 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 and reliable medical transcription services from TransDyne, click here