For a professional medical transcription service, quality is one of the fundamental tenets. Here we examine how quality of medical records can be ensured.

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Increased Importance of Clarity of Medical Documentation
in Patient Care
For a professional medical transcription service, quality is one of the fundamental tenets.
Here we examine how quality of medical records can be ensured.
Medical documentation is a major preoccupation of physicians which has to be performed
with utmost care and concentration. Ideally, they should be able to do this uninterrupted
and in their own preferred style. With most healthcare providers, the dictation-medical
transcription process is the most welcome option. With EHRs becoming mandatory,
manufacturers are vying to create EHR-integrated mobile speech solution that would
provide caregivers with diverse options for capturing and editing dictations and feeding the
documentation directly into patient encounter templates within the facility’s EHR system. A
recent development in this direction is Entrada’s release of its new module Entrada Rhythm.
This module enables caregivers to speed up the capture of clinical documentation and
improve the overall quality of the patient’s medical record.
Quality no doubt is paramount in healthcare documentation and it ensures patient safety
and documentation integrity. For a professional medical transcription service, quality is
one of the fundamental tenets. Today, with advanced software and equipment like speech
recognition, adoption of electronic health record, template-driven tools for transcription
services etc, quality health care records can be achieved.

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Customized Software to Suit Every Caregiver
With Entrada Rhythm, administrators and caregivers can choose their preferred
documentation workflow (direct EHR input, speech-to-text, transcription). They can change
this preference throughout the day as the demands on their time change. Moreover, the
system’s patient-centric Mobile Engagement Platform includes a real-time clinical schedule,
secure image capture, real-time clinical content synced from the EHR and EHR-integrated
secure text messaging. Its mobile editing capability includes the first-ever “clinical
keyboard” built specially for editing speech-recognized medical documentation on a
smartphone. The caregiver can send the speech-recognized text directly to the EHR
templates and self-edit it later, or send it to a medical transcription service company for
editing. Organizations have the flexibility to customize the solution for each user – whether
it is a surgeon, family practice physician, nurse or other caregivers.
So that’s how EHR software is being customized to provide maximum value for users.
Meanwhile medical transcription companies also continue to incorporate more features to
provide value-added services to their clients. There is no denying the fact that medical
transcription as a service will continue to enjoy considerable demand in the healthcare
scenario, albeit in a different role maybe. After all, with their vast experience in the field,
medical transcriptionists will ensure maximum quality and accuracy for the medical record.
A good partnership between the caregiver and the transcriptionist who transcribes and edits
the report ensures integrity in healthcare documentation. It is essential for the
physician/caregiver to ensure clear, complete and unambiguous dictation. The
transcriptionist in turn has to preserve the author’s style and intended meaning. The reports
must be transcribed or edited completely. In reliable medical transcription outsourcing
companies, the transcriptionists are committed to the documentation process and through
continuing education ensure integrity to the process. In addition, they make it a point to
report errors and problematic practices that may potentially cause errors and thereby bring
more integrity into the process.
Guidelines for Maintaining Quality Medical Records
That brings us to how healthcare organizations can ensure high quality medical records.

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 Health care reports should be accurate and include complete details of the
patient encounter
 Medical records should be distributed and made accessible to the physicians and
other hospital administrators in a timely manner
 Medical documents must be reviewed by qualified reviewers in a consistent and
impartial manner
 Random sampling of medical records should be regularly audited using a
complete audio review to ensure that the transcribed/edited documents are
accurate
 All errors should be brought to the notice of the transcriptionist, editor and/or
others who created the report and corrected to improve quality and continuing
education
 Up-to-date reference materials must be available to all transcriptionists and QA
personnel
Quality patient care can be provided only through proper documentation. A more
standardized approach towards measuring, reporting and improving the quality of
healthcare documentation will surely improve the quality of healthcare documentation and
help achieve consistent patient safety outcomes.