7 Ways in Which a Medical Transcriptionist Ensures Accurate Clinical Documentation
1. 7 Ways in Which a Medical
Transcriptionist Ensures Accurate
Clinical Documentation
MEDICAL TRANSCRIPTION SERVICE COMPANY
8596 E. 101st Street, Suite H
Tulsa, OK 74133
Phone : 1-800-670-2809
This article highlights 7 ways in which a good medical transcriptionist
ensures accurate medical transcription.
2. www.medicaltranscriptionservicecompany.com 1-800-670-2809
Medical transcription is the critical process of transcribing a physician’s notes into
accurate medical records. Medical reports are documents that record patient details and
contribute to high quality care. They enhance communication between patients and the
various healthcare providers. They reduce many hassles associated with medical claims
processing and also serve as legal documents when needed. Hence accurate medical
documentation is essential and this can be achieved with the help of skilled and
experienced medical transcriptionists.
How a Medical Transcriptionist Ensures Accuracy
Here are seven ways in which an experienced medical transcriptionist would ensure that
your medical documentation is accurate and reliable.
Check and recheck the final records
Once the documentation is done, the final records would be thoroughly proofread
to detect any errors. Proofreading and rechecking of the documented facts
ensures that the patient’s name, medical details and dates are entered correctly.
This will also provide the opportunity to correct any inconsistencies in the
documents.
Apply their knowledge about medical terminology, anatomy and
physiology
Good medical transcriptionists will be well aware of relevant medical terminology,
anatomy and physiology, lab and radiology values. They can easily identify any
incorrect entries regarding dosages of medications. They would:
Know what drugs work for what medical condition
Have a clear understanding of the body parts and their functions
Know common lab values to identify outliers
Knowledgeable about age- related illnesses, conditions or disorders
Utilize drug book and other tools for reference
A dedicated medical transcriptionist will usually have a drug book for ready
reference and to know the dosage details. They would also make good use of the
various research resources available and reliable websites to ensure accuracy
when the dictations are confusing and ambiguous. Sample dictations (from
specific dictators from which protected health information has been scrubbed)
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may be used to clarify later dictations since physicians often use the same
phrases while dictating and use of these samples helps in transcribing dictations
accurately.
Make use of their excellent listening skills
A good medical transcriptionist would employ his/her keen listening skills to
capture every important word dictated by the physician even when there are
disturbing background noises. They would notify the physicians if there are
medical discrepancies. Listening simply to the dictated words is not enough,
understanding the meaning is also essential since it will limit the need for
correcting errors in the medical records. This is what reliable medical
transcriptionists ensure.
Work with the physicians
It is important that transcriptionists work closely with the physicians if
documentation is to be efficient. If any doubt arises at the time of transcribing,
they would clarify the same with the physician and make sure that the medical
records are error free and accurate.
Keep abreast with new changes in the medical industry
Medical transcriptionists should be aware about the changing trends in the
medical industry. They keep themselves updated regarding new and innovative
treatment methods, terminology, new drugs etc. This helps them minimize errors.
The innovative method of speech recognition documentation requires special skills
and techniques and medical transcriptionists educate themselves on this
technique as well.
Stay relaxed
A medical transcriptionist focused on creating accurate medical records knows the
importance of staying relaxed and getting sufficient rest. This will ensure that
they can deliver medical records with fewer errors.
The Significance of Medical Transcription Services
Irrespective of the method of dictation, accurate medical documentation can be ensured
with the support of dedicated medical transcription services. They offer various
transcription options and customized services at affordable rates. An experienced
medical transcription company ensures: