Medical Transcription: Understanding and Overcoming Transcription Errors
In medical transcription the dictation is converted into a voice file and sent to the medical transcriptionist through internet. The transcriptionist attentively listens to it and converts it into an electronic file. A poor recording, heavy accented voice, background disturbances, loss of concentration, improper knowledge of medical terminology and typing errors are some of the major reasons behind errors in transcribed reports.
Generally any transcribed report having accuracy of more than 98% is accepted as reliable medical document and is used by the physician to treat the patient. The errors are categorized as follows:
- Critical Errors – The mistakes in Patient ID, omission in dictation or a missing part and misuse of medical word so that it severely compromises the safety of the patient information. A transcription report, which has one or more, such type of errors, is rejected.
- Major errors- The errors like wrong verb usage, spelling mistakes, failure to raise flag for quality audit or misusing the flagging right. A transcribed report having three or more such types of errors is rejected.
- Minor errors- The grammar or format mistakes or any other errors, which have very less impact on the safety or the integrity of the medical report, fall under this category. A transcription report, which has nine or more such type of errors, is rejected.
A higher frequency of errors in the medical transcription report points towards poor quality standards of the transcription company and casts a bad impression about the professional competence of the service provider. The time, money and manpower spent towards correcting the errors increases the production cost and thus reduces productivity. The turnaround time also increases and prevents in timely delivery of treatment to the patient.
Overcoming Errors
To increase the productivity it necessary to attain high degree of accuracy. A detailed analysis of the transcription process will help to identify bottlenecks, which induce errors in the final outcome. Mentioned below are the some important quality enhancing steps, which increase the accuracy of the transcription report.
- Provide rigorous training to medical transcriptionists.
- Assign a small group of transcriptionists to a particular dictator so that voice pattern and dictation style can be familiarized.
- Synchronize use of Speech recognition software with transcriptionists. The software will speed up process, while the transcribers will edit errors in the report. This will reduce fatigue on medical trancriptionists and thus minimise errors .
- The MT should update their knowledge of medical terminology, regularly.
- The quality control department should work closely with transcribers and provide a complete feedback of the quality of transcribed reports. The audit department should help transcriptionist of identify their weakness and work with training department to iron them out. This will surely raise the quality standards of the final output.
- Sharpen listening skills of the transcribers and editing skills of proofreaders or editors through in house training to filter out the errors.
The accuracy of the transcribed is of paramount importance because the physician depends on it to deliver the treatment to the patients. Any error, carried forward can alter the outcome of the treatment and seriously undermine the health of the patient.
To eliminate the transcription error it is necessary to understand it’s source.
Jason Gaya
Read more on medical transcription at, www.mediscribes.com
February 2, 2010
Medical Transcription- Synchronizing with EMR to create a Better Medical Documentation system.
Medical transcription is a process in which the health information of the patient is dictated, stored and transmitted to a transcriptionist as voice file. This is converted into an electronic format like a computer text file and sent back to the physician, who stores it in his or her computer, for later use.
The EMR or Electronic medical record is medical documentation system in which the information of the patient is directly fed into the computer by selecting related terms from pre-structured point-and-click templates. The doctor simply points and clicks on the appropriate clinical terms from the available choices to enter medical observations of the patient.
Electronic medical record or electronic health record is gaining in importance as it allows the doctors to store and manage efficiently voluminous protected health information in safely. The information can be retrieved easily whenever needed. The medical information of a particular patient stored by one doctor can be easily used or updated by another doctor during the course of treatment. This provides a greater flexibility to the treatment process. As this form of documentation process has lesser human interference it is prefered by tech savvy doctors over medical transcription.
But medical transcriptionists can bridge this gap between these two forms of medical documentation systems to create more efficient system where both of them complement each other. The transcriptionists provide the trained eyes and are better trained to process the information without errors. Also extra safe guards like, quality control audits ensure high accuracy rates in the medical transcription. This feature is missing in the EMR as everything depends on what the doctor enters into the template with no crosschecks in place. Wrong information entered can be carried forward or used by other doctors.
Further the output from templates is too canned and identical in EMR. It loses individuality for each patient and this shortcoming can be well addressed in the transcription process where the description of the patient is vividly converted into a detailed electronic record that is customized to address medical requirement of the patient. Some doctors prefer EMR while other prefer medical transcription due to their own advantages and disadvantage that these two form of documentation offer.
But transcriptionists can play a pivotal role by helping the medical fraternity to harmonize EMR with medical transcription by providing the much needed reliability in form of trained eyes and human instinct. By synchronizing both these documentation systems it is possible create a better and larger medical documentation system, which efficiently manages the protected health information of the masses in accost effective manner and at same time adhere to HIPPA norms.
Medical Transcriptionist can bridge the gap between medical transcription and EMR to create a better documentation process.
Jason Gaya.
Read more at, www.mediscribes.com