2. Medical Transcriptions
Medical transcription is the
art (and science) of
capturing physicians’
dictated words in a report
accurately, an increasingly
important task when
considering the growth of
electronic health records
across all medical practices
in recent years.
by: Jim Plewa, Chief Operating Officer of CaseReader™ 2
3. Medical Transcriptions
The production of medical
transcripts is a time-
consuming task but
accuracy in a patient’s
history is paramount,
especially when more
medical professionals
across a variety of
specialties will access the
same report during their
interactions with a
patient.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 3
4. Medical Transcriptions
No longer are medical records simply tied to a single practice and,
therefore, medical transcription services are increasingly
overwhelmed with requests for clear and accurate medical
transcript production.
by: Jim Plewa, Chief Operating Officer of CaseReader™ 4
Many practices outsource this
work to those trained as
medical language experts but
this field of medical
administration is also the
focus of innovative voice
recognition technology to aid
in producing these medical
transcripts.
5. Medical Transcriptions
A patient’s medical transcript will contain a wealth of information,
including their symptoms, medical history, family history, test
results, details of prescriptions and procedures and a diagnosis.
by: Jim Plewa, Chief Operating Officer of CaseReader™ 5
Whenever a patient visits
their physician and
undergoes an
examination or spends
time talking through their
symptoms and/or
progress the physician
will make a record of the
outcome of the visit.
6. Medical Transcriptions
Oftentimes, a physician uses a
handheld voice recorder to
dictate notes after the
patient has left and these
will be then be passed on to
a medical transcriptionist.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 6
7. Medical Transcriptions
Producing a medical transcript is not as simple as typing
out the words spoken by the physician as a patient’s report
is considered a legal document and requires specific
formatting.
Once the transcript is complete it is entered into the
patient’s file and can be called on in the future by the
physician themselves or by another specialist treating the
patient.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 7
8. Medical Transcriptions
The correct formatting, review and editing of a medical
transcript is important as this not only makes it much
faster for physicians reviewing the patient’s history, it also
means that an improperly recorded medication is
identified quickly and can be corrected to avert risk.
The physician providing the dictated notes is supposed to
review the transcript upon completion but, in practice,
some physicians do not review these transcripts and they
are marked instead as “dictated but not read” to signal
that there may still be potential accuracy issues.
by: Jim Plewa, Chief Operating Officer of CaseReader™ 8
9. Medical Transcriptions
Medical transcribers can also flag a transcript if they spot
inconsistencies in the report or if the words captured by
the recorder were unrecognizable.
Slow, precise and concise speech is vital to helping a
transcriber produce accurate work and the same is true for
voice recognition technology when dictating the names of
medications, the procedure undertaken and the diagnosis.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 9
10. Medical Transcriptions
Medical transcribers have to
contend with regional and even
national accents, rushed speech
(particularly from Emergency
Department physicians
physician), mispronunciations
and abbreviations of medical
terminology, disordered speech
when a physician recalls
something out of the context of
the current sentence, and even
incorrect dosages or other errors.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 10
11. Medical Transcriptions
The transcriber must also make sure to check references
and the proper spelling of medical terminology and
highlight any problems they see in the report for the
physicians review. Medical transcriptionists need to
constantly be updating their database of new medical
equipment, drugs, devices and nomenclature in order to
produce accurate reports and this is just one area where a
centralized database available with voice recognition
software is helpful.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 11
12. Medical Transcriptions
Physicians looking for
efficiencies can also
improve the accuracy of
their own dictation,
produce clearer medical
transcripts that are
properly formatted and
easy to review while
reducing wait-times for
outsourced medical
transcription services by
using medical speech-to-
text voice recognition
technology such as
M*Modal Fluency.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 12
13. Medical Transcriptions
One solution CaseReader™ by DPR
has embedded M*Modal voice
recognition technology.
Within CaseReader™ Fluency is
utilized for navigation and dictation
in a templated environment to
produce timely and accurate clinical
documentation.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 13
14. Medical Transcriptions
The all-software solution enhances
productivity and may increase
revenue by ensuring accuracy and
safety in patients’ medical
transcripts.
Its seamless integration with the
ability to embedded images in the
final report make CaseReader™ a
valuable tool for radiologists and
referring physicians.
by: Jim Plewa, Chief Operating Officer of
CaseReader™ 14
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Medical Transcriptions
Written by:
Jim Plewa
Chief Operating Officer
CaseReader™
Connect with Jim on:
http://www.linkedin.com/in/jimpl
ewa
https://twitter.com/Jim_Plewa
