Delivering the “Best Quality” has become one of the greatest challenges in the new millennium. The healthcare industry needs to meet the desired standards of quality and accuracy in documentation and therefore there is an increasing demand for medical transcription day by day. The HMOs, accreditation boards and government offices now call for maximum quality at minimum cost. In the case of transcription, excellence and quality play a more significant role than quantity. Therefore, professional medical transcription services have skilled experts that ensure accuracy in data and quality of documents. Medical transcription quality assurance has emerged as a key component in ensuring that transcribed medical records meet the highest standards of accuracy and reliability.
Quality assurance (QA) is an important element in the medical transcription process. Dependable service providers are focused on maintaining accuracy levels of up to 98% or more in the medical transcripts for hospitals, clinics and individual physicians. Expert proofreaders and editors in the QA department review the transcribed files at three levels. The quality of a transcribed page can be measured in terms of the percentage of accuracy of the transcribed documents. Industry standards require that up to 99% accuracy should be maintained in the transcripts. The audio provided for transcription should be of good quality.
Different Levels in the Medical Transcription Quality Assurance Process
- The first level is the process of medical transcription done by medical transcriptionists.
- At the second level, the files are checked by a proofreader (PR). The proofreader examines the working document for integrity of content.
- At the third level, the files are checked by a quality controller (QC)
- The final level of checking is done by the quality auditor (QA). He will analyze the quality of the delivered product and check the overall quality of the files done at all the previous levels. This layered process is central to QA in healthcare transcription, ensuring accuracy at every stage.
Guidelines for Quality Assurance
It is the responsibility of the service providers to maintain and follow a quality assurance policy based on the following guidelines:
- The quality process should be made available to all the workers involved in the transcription process including the transcriptionists, proofreaders, editors and quality assurance team.
- The quality assurance program should not affect the outcome of the documentation process including the progression of work, turnaround time and technology.
- It is important to make necessary modifications in the QA policy according to requirements and specifications.
- Proper training should be given to the QA staff.
- Create and plan a budget for implementing the quality assurance program.
- Follow all the guidelines and rules for good quality assessment
By understanding how QA improves accuracy in medical transcription, medical transcription companies can develop solid procedures and invest in quality personnel and tools. Adhering to these principles ensures consistent and precise healthcare documentation.
What Medical Transcription Companies Regularly Do
Reliable medical transcription companies implement diverse quality control measures and follow state-of-the-art documentation procedures to accomplish their goal. For more accurate transcription, all the transcribed document reports are processed ensuring the following:
- Three levels of checking by editors, medical editors and proofreaders for 99% accuracy.
- All transcriptions are performed using software such as:
- American Drug Index
- Stedman’s Electronic Medical Dictionary along with the complete range of Stedman’s books
- Utilizes Microsoft Word 97/98 and 2000, WordPerfect 9, sound / media players and converters such as Windows Media Player, GoldWave, DVIPS, MSV, WinAmp, DVF, ICS, DSS and PC Dart PlayAll for the adjustment of pitch and speed.
These providers have a QA team that has an excellent eye for detail and is adept in all aspects of medical transcription. Team members have knowledge about chief body systems and diseases, and can detect errors in
- Medical abbreviations, foreign terms, jargon, word differentiation, slang and plurals in medical language
- Layout of fundamental hospital reports
- Roots, prefixes, suffixes and combinations associated with medical word building
- English spelling, grammar, punctuation and style
This extensive transcription error detection process allows for corrections before delivery, which is essential for protecting patient care outcomes and minimizing liability.
Quality Assessment Personnel
The quality assessment personnel required in a medical transcription company are:
- Medical Transcriptionists
- Quality Editors
- Quality Manager
In its Statement on Quality Assessment for Medical Transcription, the AAMT (American Association for Medical Transcription) has classified transcription errors in the following manner.
- Critical Errors: Those errors which impact patient safety such as medical term misuse, incorrect drug or drug dosage, wrong lab values and test names, omitted dictation, patient identification error.
- Major Errors: Errors which impact document integrity, which include medical word misspelling, English word misspelling, failure to flag a document, abuse of flagging documents, protocol failures.
- Minor Errors: These include grammar, punctuation, typographical errors, and various formatting errors.
- Dictation Flaws: These have been classified into critical, major, and minor as defined by patient safety and document integrity impact. In medical transcription, it is very important to understand the impact of the voice quality of dictation on the transcript.
To ensure quality across all documentation, many organizations follow a structured medical transcription QA checklist for healthcare providers, which outlines best practices for minimizing errors and streamlining workflows
Quality Is What Really Matters!
Quality can be achieved through a well-planned set of actions designed to meet the expectations of the end-user. The quality control program for healthcare documentation aims at ensuring clear, accurate, timely, and consistent patient care documentation that satisfies all documentation requirements. These documents will be a model for the implementation of the quality assurance program compatible with hybrid EHR record systems, paper-based medical records, and electronic health record systems. Properly executed proofing and editing in transcription, and state-of-the-art quality control in medical transcription services helps avoid wrong treatment and malpractice lawsuits, thereby safeguarding the healthcare provider’s integrity and reputation.
