Medical Transcription: Everything You Need to Know and More
Healthcare professionals have a busy and stressful job. Now add hours spent typing medical notes for record keeping. This not only limits hours spent on patient care but is tedious and time-consuming.
Some healthcare professionals hire assistants to transcribe their notes, but experience delays and inaccuracies. They aren’t trained professionals who have experience in medical transcription.
Moreover, medical notes are extremely important documents, and errors can compromise patients' health and subject the doctor to medical malpractice lawsuits.
What is medical transcription?
A medical transcript is a written document that is typed from a dictated audio file recorded by a doctor, nurse, or other healthcare professional. This process is known as medical transcription.
What is the result of medical transcription?
Medical transcription generates various types of reports based on different stages of patient care. Some of the examples include:
Consultation report: The consultation report comes from the consulting doctor and not the admitting doctor. It contains a brief explanation of the patient’s disease and a specialized physical examination tailored to the sort of consultation requested. Additionally, it might incorporate lab or x-ray results. The doctor's assessment and treatment strategy is provided as the report's conclusion.
History and Physical report: When a patient is admitted to the hospital, doctors typically need them to write this report. The main complaint comes first, then the patient's present illness history, medical history, social history, and their family's medical history. This is regarded as the patient's final physical examination and concludes with a diagnosis for admission and a treatment strategy.
Operative report: The operating physician writes this report, which contains a thorough account of the operation. Details include pre and post-operative notes, the type of operation, the surgeon's and anesthesiologist's names, and a thorough explanation of the actual surgical procedure. The number of devices used, blood loss, etc., are all mentioned according to the type of surgery. The report will conclude with the patient's general state of health, where they were taken after leaving the operation room, and the disposition.
Pathology report: The pathologist's instructions are included in this report, which also provides the sample's microscopic results.
Radiology report: Once the diagnosis and radiographic treatments are finished, the radiologist dictates this report. It contains the radiologist's conclusions and analyses of nuclear medicine tests, MRIs, CT scans, and other imaging techniques.
Hospital report: All hospital reports that were dictated, such as radiology reports, pathology reports, and laboratory reports, are included in this.
Laboratory report: The results of tests done on bodily fluids including blood levels and urinalyses are included in this report. Rarely is this report dictated independently; instead, it is frequently a part of the History and Physical examination (H&P), consultation, or discharge summary.
Discharge summary: At the conclusion of the patient's hospital stay, the doctor dispenses a discharge summary. From the patient's admission to discharge, all significant reports are included. A thorough plan for the patient is included in the report's conclusion. The report's summary changes from discharge summary to transfer summary if the patient is transferred to another institution. A discharge summary is referred to as a death summary if the patient passes away.
Office reports: Office reports are documents that are prepared in a medical practitioner’s office and are not treated as hospital reports. Some of these are initial evaluations, letters to referring physicians, patient introduction letters to specialists, and chart notes for each visit.
What do medical transcriptionists do?
A medical transcriptionist types a doctor’s spoken words during an account of a visit so that the patient’s health history is recorded. Medical transcriptionists employ their in-depth understanding of medical language and critical thinking abilities when transcribing to ensure that errors are kept to a minimum.
They pause and seek clarification if they come across contradictory information, such as someone listed as taking a drug they are allergic to, to ensure the record is true.
Responsibilities and duties of a medical transcriptionist include:
- Transcription of patient data, including name, social security number, and medical history
- Examining the sources for medical terminology and medical procedures
- Accurately transcribing and correcting any inaccuracies
- Preserving a log of transcriptions
- Following up on doctors' dictation and promptly sending reports back
How to become a medical transcriptionist?
There are certain sets of requirements to become a medical transcriptionist at Reduct.Video. At a minimum level, the transcriber must have a high school diploma or GED. Along with this, fast, accurate typing, listening skills, organizing and communication skills, and a working knowledge of computers are required. Furthermore, specialized knowledge of medical terminology and reports along with HIPAA compliance training is required before working on medical documents.
What is the benefit of medical transcription?
Medical transcription allows the exchange of information between medical specialists and ensures that every healthcare worker is on the same page. This helps ensure every patient receives proper diagnosis and treatment, thus is crucial to the healthcare industry.
Medical transcripts can be saved and shared easily. Compared to audio recording, medical transcripts help health professionals skim through the information without having to listen through the entire audio file.
A medical transcription company understands the importance of accurate transcripts and that mistakes can put patients' health in jeopardy and doctors at risk of losing their medical licenses. In addition to transcribing, medical transcriptionists edit and format documents as per your request and return them safely.
Things to consider while choosing medical transcription services
1. Cost: The cost should be reasonable and affordable for your company. Most medical transcription companies charge per minute of audio, so the cost will vary based on your audio volume.
2. Experience: Not every organization is able to deliver excellent outcomes when it comes to medical transcription. The experience of a company can be used to determine transcripts that are reliable, accurate, and have a timely delivery.
3. Accuracy: It is important to choose a medical transcription provider that guarantees an accuracy of at least 98 percent. The accuracy rate will also depend on how many people proofread the paper before it is delivered back to your office. If the work is proofread by three to four people, errors will be found and fixed before it is sent to you.
4. HIPAA compliance: Medical transcription contains patients’ healthcare data that as per law is required to be kept private. Choosing a HIPAA-compliant transcription company ensures the Protected Health Information (PHI) & ePHI of patients is private and secure.