Medical professionals deal with multiple patients daily. The notes medical professionals dictate for various medical reports must be documented correctly. Correct documentation is essential for delivering quality healthcare to patients.
Most medical practitioners dictate their notes through an audio recording, which needs to be transcribed. Transcription of patient data is usually done by requisitioning the services of specialized agencies offering medical transcription services. Errors in the medical transcription process can have severe consequences for all the stakeholders in the healthcare delivery process.
Transcribed documents are vital for maintaining a record of a patient’s case history, diagnosis, and treatment and help with any reimbursement claims. Increasingly, healthcare providers are moving towards using a medical billing company to streamline the billing and the claims’ disbursal process.
In medical transcription, speed and accuracy are critical. The balance between the two is difficult to maintain. The balance is an especially tricky proposition in healthcare, since one is dealing with the health data of human beings. However, efficiency concerning time is essential, and transcripts are required in the shortest possible time. Quick turnaround times are the norm in the medical transcription industry.
Fortunately, some simple measures ensure accurate medical transcription. These measures include:
- Quality of Recordings — A poor audio recording quality renders transcribing difficult and increases the chances of transcription errors. Medical professionals should dictate their report in a quiet room with no ambient noise and speak clearly.
- Timely Recordings — Medical professionals should dictate the patient notes immediately after seeing the patient. It ensures that no relevant information is missed and reduces the risk of errors. Also, dictating reports on surgery/other medical treatments soon after the actual surgery/treatment helps speed up the revenue cycle.
- Deploy Experienced Personnel — Whether the transcription personnel are in-house transcriptionists or the work has been outsourced to a medical transcription services agency, experienced and qualified individuals must be deployed for quality work—medical transcription demands personnel with high levels of skill, training, and experience.
- Leverage Technology — Outdated recording equipment or software can adversely impact the quality of the dictation and transcription process. Adopt a tech tool that is easy and intuitive to use. Customisable apps are now available that help doctors with the dictation and documentation process, helping eliminate delays and improving overall accuracy and efficiency.
- Accuracy Over Speed — The medical transcription system, as currently structured, incentivises speed. Reduced transcription time reduces turnaround time and provides the business with a monetary advantage. However, the undue privileging of speed over accuracy increases rework and a monetary disadvantage in the long term. However, touch-typing software can enhance accuracy without compromising on speed. For accurate billing, the services of a medical billing company can be availed.
- Sentence-by-Sentence Transcription — After listening to the complete audio, transcription is done sentence-by-sentence to minimise errors. Listening to the whole audio first – helps get a clear picture of the overall task. This approach reduces errors since there is greater awareness of the context of the sentence.
- Run a Check for Critical Errors — For verification and evaluation of the transcribed document, good proofreading skills helps weed out critical grammar and sentence composition errors. It is essential to be vigilant to ensure the correct and accurate usage of medical terminologies.
- Industry Certifications — Industry-recognised organisations that issue certificates and provide training on medical transcription help. Good training helps reduce errors. Training programs also include grammar, medical terminologies, and core transcription skills. The importance of accuracy in healthcare services and the highly competitive nature of the transcription services industry make accuracy doubly important. For accurate medical transcription services, one can engage specialised agencies.
- Typing Skills — After obtaining certifications and training, improving typing skills also helps increase accuracy. Typing skills can be continuously enhanced with practice.
- Competent Editing — Checking for errors in the shortest possible time is critical in this profession. Editing is, therefore, an integral part of the process and improves accuracy. Despite care and training, some syntactic, spelling, grammatical, and factual errors creep into the transcribed document. Competent editing eliminates such errors.
- Familiarity with Medical Terminology — A basic understanding of commonly occurring medical terms helps eliminate many errors. Medical professionals’ knowledge of standard abbreviations also helps improve medical transcription accuracy. The better informed, the lower the chances of mistakes. Agencies providing good medical transcription services are mindful of this and train their employees to deliver superior transcription services.
- Numeric Errors — Medical reports generally contain multiple instances of prescriptions with specifications of drug dosage. These need to be transcribed accurately. Utmost care needs to be taken for accuracy on this account – errors can have catastrophic consequences.
Medical transcription is a vital function of the healthcare industry. It is a task that requires sound knowledge of medicine and health-related issues. In addition, one also needs to be passionate about grammar and writing, have an eye for detail, impeccable accuracy, good typing skills, and have high concentration levels. Even though some individuals are naturally endowed with these skills, every medical transcriptionist needs to hone and maintain these skills to attain accuracy constantly.