The importance of proper documentation of the healthcare process has become even more obvious considering the current and proposed changes in the healthcare documentation scenario. Healthcare professionals and other related participants of the entire healthcare process have always needed specific information to be able to deliver quality care and deal with other aspects of running a healthcare facility.
With more and more options being available for documenting the care process - each claiming to meet the needs of the healthcare sector, it has become imperative for healthcare facilities and healthcare professionals to evaluate these methods to ensure that the method chosen for documenting the care process ensures specificity of information. Specificity has been defined as explicit, particular, definite, or the quality of being distinctive. In case of healthcare documentation this is important as the information in patient medical records is used for many vital purposes like the care process, coding & billing, research, defense in case of litigation etc.
Of all the methods of documenting the care process, medical transcription especially when outsourced to a professional and technologically savvy medical transcription company meets the criterion of meeting specificity of information.
Medical transcription services ensure specificity of information by addressing every step of the process:
Capturing information: The input for patient medical records is generated from the healthcare professionals at the point of care. Medical transcription companies ensure specificity of information at this stage by:
- Encouraging use of good dictation equipment and some medical transcription companies even offer dictation equipment as part of their promotional offers. Medical transcription companies also offer options like structured dictation, where the healthcare professional can dictate in a accepted pattern
- Educating healthcare professionals about good dictation practices. This ensures that the medical transcription companies have quality audio to process, resulting in quality transcription. Healthcare professionals are given regular feedback regarding the quality of dictation to encourage better dictation, which in turn leads to specific information being captured in patient medical records.
The transcription process: The actual transcription process is a vital area that needs to be focused on, to ensure specificity. Medical transcription companies ensure quality by establishing quality procedures for every aspect, this includes:
- People: One of the major components to ensure the specificity of information in patient medical records is the team involved in the process of transcription. Medical transcription companies recruit and train their team to ensure that they have both the aptitude for accurate transcription and the attitude of striving for perfection. This ensures the specificity of information in patient medical records
- Processes: Transcription needs a stringent quality process to ensure that specific and correct information is captured. Medical transcription companies ensure specificity by putting each transcript through stringent quality processes. Further more medical transcriptionists, editors and proofreaders involved in transcription are equipped with the latest reference and research materials to ensure specificity
Document delivery: Apart from ensuring transcription that captures specific information it is also important to ensure that these documents are delivered to the specific healthcare professionals and healthcare professionals through HIPAA and HITECH compliant channels within the turnaround time specified. Medical transcription companies ensure this by using convenient software and tools.
Adopting new technology: With the increasing pressure on the healthcare sector to adopt EMR/ EHR, medical transcription companies have stepped in to ensure proper adoption without disrupting the working life of healthcare professionals by adopting different techniques and technology, which ensure specific information is captured with minimum disruption:
- Speech recognition software: Providing editing and proofreading services for back end speech recognition software to ensure acceptable accuracy levels
- Discrete reportable transcription: Using discrete reportable transcription, medical transcription companies are ensuring specific data is parsed into the EMR/ EHR
- HL7 interface
- Structured dictation and transcription
It can be concluded that medical transcription companies ensure specificity of information while still ensuring enormous savings on cost.
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.
Among the software and tools offered by TransDyne for transcription, the smart delivery system has a large role to play in easing the path to EMR/EHR adoption The Smart Delivery system, which has features like User defined folder paths to enable easy imports to EMR systems is the suggested mode of document delivery where pre-defined file saving would help import documents to EMR systems. Apart from this TransDyne also offers discounted rates for those healthcare facilities that provide demographic data entered in the EMR rather than through other modes.
Along with medical transcription services involving multiple level quality checks to ensure accuracy, the use of the right technology for ease of use, turnaround time and security, at reasonable rates, TransDyne also provides discrete reportable transcription and editing & proofreading services for adoption of EMR/ EHR
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