The medical transcriptionist converts the voice file, which contains patient health information, into an electronic file. The file is encrypted as per HIPAA norms and sent back safely to the physician, who then decrypts it back to the original form. The stored information can be accessed, whenever needed during the course of treatment. Transcription process takes time and the turnaround time generally varies from 4 hours to 48 hours depending upon type of medical reports and service of transcription provider.

The emergence of new applications like speech recognition software and Electronic medical record (EMR) has increased the speed and ease with which the patient health data can be processed and stored in the computer.

Electronic Medical Record

In EMR, during the patient-doctor encounter, the clinical observations of the patient are fed into the computer by selecting the related terms from the pre-structured point-and-click template. The physician enters the appropriate clinical term from the available choices to make complete electronic record of the patient. This record can be accessed or updated by other physician during the course of treatment and thus provides great flexibility in treating the patient. EMR has inbuilt safety system, which provides medication warnings or drug allergy alerts.

One main loophole is that there is no crosschecking mechanism present in EMR, which ensures that no wrong information is entered and carried forward into treatment .This can seriously jeopardize the safety of the patient. Since the information is stored on basis of pre-structured template the output from the template is too canned and loses the individuality.

Speech Recognition Software

Speech recognition software is an excellent tool, which directly converts the spoken words into text on computer screen. Thus a physician can directly speak into the computer and see for him or herself the text on the screen. This saves times as the there is no need to send the file to the transcriptionist and this reduces the turnaround time considerably.

Shortcomings in Speech recognition Software

In spite of latest advancements is this field, the software is not completely accurate. There are errors in it and it requires human intervention to guarantee the accuracy of the final outcome. Further the software requires human training to condition it to the voice pattern and dictation style of the end user.

Medical Transcriptionist Bridging the Gap

The above shortcomings can be easily overcome by integrating the transcription process with EMR and speech recognition software. The medical transcriptionist can work in tandem with back-end speech recognition software to edit the errors in report transcribed by the software. The voice file is sent along with electronic file to transcriptionist, who then edits it.The transcribing speed increases considerably, without compromising the accuracy of the report.

The medical transcriptionist also overcomes the shortcomings of EMR. The presence of well trained transcriptionist and team of quality control department guarantees high degree of accuracy of the medical report.A pair of fresh and trained human eyes, ensure that no wrong information is fed in the electronic medical records of the patient. The transcription provides other advantage in form vivid and detailed description of the patient health which is missing in the EMR. This detailed account is necessary where the physician needs in depth knowledge about the past and present medical observations of the patient to arrive at conclusion, especially in critical and difficult cases.

Thus a medical transcriptionist plays a crucial role in integration of transcription process with EMR and speech recognition software to by overriding their shortcomings. It provides the human intelligence, vigilance and instinct to successfully integrate man, machine and software smoothly.

Transcription, EMR and voice recognition software can be integrated successfully.

Jason Gaya

Read more on, medical transcription at, www.mediscribes.com

The Physician or health specialist after diagnosing a patient dictates all the noted clinical observations into a recording device. The recorded report is transmitted over the internet, as a voice file to the medical transcription service provider. The transcriptionist attentively listens to the recorded voice and types the information into the computer, to create an electronic file. This file after stringent quality control checks is sent back to the physician, who stores it in computer for future reference. During the transcription process, following equipments are used:

• A computer connected to internet.
• A head set to listen to voice file.
• A foot pedal to pause the recording whenever necessary.

The medical transcriptionist transcribes variety of health reports and these include:

• Patient Discharge reports.
• Medical history of patient
• Physical examination reports.
• Operative reports.
• Consultation reports.
• Autopsy reports.
• Diagnostic-imaging reports like radiology, MRI and ultrasound.
• Post operative progress reports.
• Referral letters.

It is important that transcriptionist must be trained in medical terminology and should have good knowledge of:

• Human anatomy and physiology.
• Medical diagnostic procedures.
• Pharmacology.
• Treatment assessments.
• Medical jargon and translate them into expanded form.
• Standard reference handbook both in, electronic and printed version.

The medical transcriptionist should be skilled enough to spot mistakes or inconsistencies in the medical report. This saves the patient from receiving wrong treatment as a result of errors in the transcribed reports. Besides accuracy, the transcriptionist should to also have good speed to deliver back the transcribed report in a very short turnaround time. This helps concerned physician to deliver the requisite treatment to the patient in minimal time, thereby increasing the patient care. Finally the HIPAA compliance norms make it mandatory for the covered entities like the hospitals, clinics and doctors to protect the privacy of patient health information. Hence it is moral duty of the transcriptionist to maintain the secrecy of the patient information as per HIPAA norms.

Medical transcriptionist play an important role in increasing patient care through better documentation of  health information.

Jason Gaya

Read more on medical transcription at, www.mediscribes.com