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Medical transcription at Affordable Rates


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Medical transcription at Affordable Rates

  2. 2. Objectives Know the Healthcare Industry and Process What is Medical Transcription? Medical Transcription Process Different types of Patients Different Providers Various Reports Skill Set to perform Medical Transcription Scope and Future of Medical Transcription
  3. 3. US HEALTHCARE PROCESSAppointment Registration Financial Discussion EncounterBilling InsuranceClaims AdjudicationPayment or No PaymentSettling of Patient’s AccountCollecting Balance fromPatientInsurance
  4. 4. BriefTake an appointmentRegister oneself in Provider’s office and their softwareDo a finance discussion for the paymentMeet the Provider for treatmentGenerate Bill to be sent to InsuranceLet the bill be processed at the insurance end with the details sentresulting in either payment or denialSettling of the patient’s accounts as per the Insurance follow upBalance billing to the patientCollect balance amount and reschedule for next appointment
  5. 5. Medical Transcription:Medical transcription is an allied health profession, whichdeals in the process of converting pre recorded providers voicefiles into text files/documents. These files after conversion arecalled as transcribed reports or sheets.VOICE FILE MEDICALTRANSCRIPTIONIST TRANSCRIBED SHEET /MEDICAL RECORDS
  6. 6. Medical Transcription ProcessWhen any patient visits a doctor, the latter spends time with the formerdiscussing his/her medical problems, including history and/or problems. Thedoctor performs a physical examination and may request various laboratory ordiagnostic studies; will make a diagnosis or differential diagnoses, then decideson a plan of treatment for the patient, which is discussed and explained to thepatient, with instructions provided. After the patient leaves the office, the doctoruses a voice-recording device to record the information about the patientencounter. This information may be recorded into a hand-held cassetterecorder or into a regular telephone, dialed into a central server located in thehospital or transcription service office, which will hold the report for thetranscriptionist. This report is then accessed by a medical transcriptionist. It isreceived as a voice file or cassette recording. In turn the transcriptionist listensto the dictation and transcribes it into the required format for the medical record,and of which this medical record is considered a legal document. The next timethe patient visits the doctor, the doctor will call for the medical record or thepatients entire chart, which will contain all reports from previous encounters.
  7. 7. Types of Patients:
  8. 8. Types of Physicians:
  9. 9. Types of Medical Reports (Major Ones):History and Physical (H&P): This report is usually dictated by the admittingphysician or resident when a patient is admitted to the hospital. It usuallybegins with a chief complaint. The “history” includes a history of the presentillness, past medical history, social history, and family medical history.Smoking can go under the heading of either Social History or Habits. There isusually a review of systems and a complete physical examination from head totoe. The report usually ends with an admission diagnosis and a plan for thepatient’s treatment.Consultation (Consult): This report is usually dictated by a physician to whomthe admitting physician has referred the patient. Therefore, the consultingphysician is usually a specialist in an area other than the admitting physician.Sometimes consultations are requested for second opinions. Consultationreports usually include a brief history of the patient’s illness and a specificphysical exam depending on the particular type of consultation requested. Thereport may also include laboratory or x-ray findings. The report usually endswith the consulting physician’s impression and plan, and sometimes a commentfrom the consulting physician thanking the admitting physician for the referral.
  10. 10. Types Of Medical Reports (Major Ones) Contd…..Operative Report(OP): This report is dictated by the operating physician andcontains detailed information regarding an operative procedure. Included in thisreport are preoperative and postoperative diagnoses, the type of surgery or surgeriesthat were performed, the names of the surgeon(s) and attending nursing staff, thetype of anesthesia and the name of the anesthesiologist, and a detailed descriptionof the operative procedure itself. Depending on the operative procedure, informationregarding instrument counts, sponge counts and blood loss are also dictated. Oftenthe report will end with disposition or where the patient was transferred when he leftthe operating room (usually recovery room) and the condition of the patient at thetime of transfer.Discharge Summary (DS): This report is dictated by the admitting physician at theend of the patient’s stay in the hospital. It includes a summary of everything thatoccurred from admission to discharge, including laboratory data, x-ray data, andpertinent physical findings throughout the hospital course. The report usually endswith the discharge diagnosis and a detailed plan for the patient. If the patient istransferred to another institution (such as a nursing or other hospital), the name ofthe report is usually changed from discharge summary to transfer summary. If thepatient has expired (died) during the hospital stay, the report is usually called a deathsummary.
  11. 11. Types Of Medical Reports (Major Ones) Contd…..Radiology Report: This report is dictated by the radiologist upon completion of adiagnostic procedure and includes the radiologist’s findings and impression.Examples of radiology reports are x-rays, CT scans, MRI scans, nuclear medicineprocedures and fluoroscopic studies.Pathology Report: This report is dictated by a pathologist and describes findings ofa tissue sample. The focus of the report is on the microscopic findings and thepathological diagnosis of the sample.Laboratory Report: This report describes findings of examinations of bodily fluidssuch as blood levels and urinalysis. Laboratory reports are rarely dictated separatelybut are often included inside the H&P, consultation or discharge summary.Miscellaneous Reports: Other miscellaneous hospital reports include cardiaccatheterizations, electrophysiology studies, phacoemulsification, autopsies andpsychological assessments.
  12. 12. SKILL SETS REQUIRED TO PEFORM MEDICAL TRANSCRIPTION1. Strong English Grammar.2. Compelling interest in the medical field.3. Superior research skills.4. Competent use of computer.5. Keen listening skills.6. Fine attention to details.7. Commitment to lifelong learning.8. Ability to sit and concentrate for long periods of time.
  13. 13. FUTURE AND SCOPE OF MEDICAL TRANSCRIPTION• Bureau of Labor Statistics predicts a need for 5.3 millionhealthcare workers.• Supply not keeping up with demand.• Aging population will put increasing pressure on the unpreparedhealthcare system in USFUTURE IS BRIGHT- for professionals looking for a careers and not just a job.- for professionals willing to commit to lifelong learning.- for professionals willing to embrace standards andcredentialing
  14. 14. Thank You