Medical transcription is one of the most time-saving and essential services that healthcare professionals can use to generate accurate medical records. It helps in recording and dictating important notes, generating patient information, and securely transforming the recordings into accurate transcripts. Medical transcription requires excellent training and listening skills on the part of the transcriptionists, and only a professional medical transcription service can provide utmost accuracy.
Medical records should be documented in a timely and error-free manner. Errors in the medical records may cause harm to the patients, and even lead to adverse events including death. Inaccurate medical records can lead physicians to take the wrong decision or treatment procedures, and it may affect the safety of the patient.
Some of the common errors found in medical records are:
- Omission of dictated words due to fast typing.
- Choosing the wrong words; due to audio issues, words may be selected wrongly.
- Misspelled words
- Typographical errors that may occur due to fast typing.
- Grammatical errors
- Punctuation errors when commas, semicolons, hyphens, dashes or quotation marks are used incorrectly, and this may change the meaning of sentences.
- Homonyms are sound-alike words and the correct word should be used to get the appropriate meaning that is consistent with the doctor’s dictation. Errors related to homonyms may occur in both English language and medical terminology.
All these are common mistakes in medical documentation and these errors may lead to poor patient care, compromise the health of the patient, and the doctor may lose his/her credibility. However, mistakes in the medical records can be minimized by proofreading and it helps to ensure accuracy. The following are the best proofreading tips to ensure accuracy of medical records:
- Concentration is important: If you want to find any mistakes, you should have a good level of concentration. So, if you are proofreading medical records then make sure to keep away from your phone, television or any device that can cause distraction.
- Keep track of all medical mistakes: Keep track of all the mistakes that commonly occur in your work. These mistakes can be categorized and reviewed so that you don’t repeat them again and again.
- Take a print copy to check: Some people may find it difficult to proofread on the screen. In such cases, you can take a printout of the report as it is much easier than reading on the screen.
- Look up in reference books or Google: Have a collection of reliable reference books, or bookmark good Internet websites. This helps in quick reference in case of any word that is wrongly pronounced or for any reference to create accurate medical records.
- Use spellchecker: You can use spellchecker for both English and medical words along with any grammar check. This will help you identify spelling mistakes, but not any other errors in transcribing.
- Look out for homonyms: Homonyms are words that have the same spelling or pronunciation but different meanings. So, switching such words can change the meaning of the sentences completely. For example, “accept” and “except.” Pay attention to such words to avoid any error.
- Check punctuations: The correct usage of punctuation is important to understand the meaning of the sentences. A common mistake found is mixing up “their” and “they’re,” “your” and “you’re.” A minor change in apostrophes can change the meaning of the sentence.
- Check figures: Stating the correct figure and value in medical reports is critical because a minor change in figures in medical records like the dosage of medicine or lab reports value can result in developing the wrong treatment plan, which could be life-threatening for the patients.
- Read it backwards: Usually, when we create medical records, we tend to ignore or become blind to our own mistakes. This is because the brain automatically corrects the wrong word into the right one. So, to avoid such mistakes it is best to read the medical record backward.
- Proofread it: Once your medical report is complete, make sure to get it proofread by someone who is a professional, like a medical transcriptionist. This helps to ensure that the medical records are accurate and error-free.
Errors in medical records may happen due to quick typing, lack of knowledge about medical terminology and jargon, background noise, and many other factors. Compromising the accuracy of medical records can affect the quality of patient care, and sometimes can be life-threatening for the patients. All of these errors and inaccuracies can be minimized by outsourcing medical transcription to reliable medical transcription company that provide EHR-integrated medical transcription. Professional medical transcriptionists are skilled, experienced, and have good knowledge about medical terminology; they can deliver the transcripts in quick turnaround time without compromising on accuracy.