Due to the rising demand for detailed documentation of medical records, many countries have begun to outsource medical transcription services from professional companies. There are many reasons why hospitals all over the world are using these services. However, one of the main reasons is the cost advantage. Apart from medical professionals gaining better benefits the MT industry too has created plenty of job opportunities for people who prefer to work from their home office or those who are looking for a second job. A doctor or a hospital and a medical transcription company work hand-in-hand in documenting a patientâ€™s record. While a doctor records all his/her interaction with the patient on the voice recorder, a transcriptionist on the other hand transcribes the recording into a detailed text. However, the process of recording and transcribing may happen at different times.
Medical Transcription Process
The interaction between a patient and a doctor involves discussing medical problems including medical history and existing conditions. The physician will then perform a physical examination, prescribe various laboratory tests based on which he/she will make a diagnosis and identify a plan of treatment for the patient. The doctor will discuss his line of treatment with the patient and provide all the necessary instructions. Once the patient leaves, the physician will record the encounter on a voice recording device. The designated medical transcription agency will accesses the recordings and transcribes it into required format for the medical records. Once the recordings are converted into a medical record, it becomes a legal document and the doctor can call for the record when the patient visits him the next time.
Duties and Responsibilities of Transcriptionists
There are various duties and responsibilities of Mt medical transcription professionals. They are responsible for various activities such as; accurately transcribing a patientâ€™s identification information such as name, social security or medical record number. Transcribing the voice recordings accurately. Utilize appropriate grammar, spellings and punctuation. Edit the report for inconsistencies. Maintain a transcription log. Consulting or maintaining references for medical procedures and terminology. Sort, copy, prepare, assemble and file records. Follow up on missing dictation, perform quality assurance check. Maintain backups. Order supplies and report operational problems. Collect, tabulate and generate reports as appropriate.
Importance of Accuracy and Quality
A doctor and medical transcriptions play a very important role to ensure that the transcribed document is accurate. Small errors can pose a great risk to the patient. Therefore, it is very important for medical transcription services provider to edit their reports and perform quality checks before submitting the document. They should have good knowledge about medical terms, names of medicines and possess hearing acuity and reading comprehension. On the other hand, doctors should speak slowly, clearly and concisely when recording or dictating details of medical conditions and medications. They should also review the transcribed document submitted by the company for accuracy.