Medical transcription results in easily accessible, legible, shareable clinical documentation which promotes patient treatment and care. A lot of factors underlie the efficiency of comprehensive report documentation such as good typing speed, superior listening skills and in-depth knowledge of medical terminology. All of these factors contribute to accuracy in documentation – the most important crucial element when it comes to ensuring proper treatment and care.
Data for transcription relates demographic data, consultations, history and physical examinations notes, inpatient progress notes, discharge summaries, operative reports, and specialty reports. Accuracy is a must in any of these documentation types but is crucial when it comes to taking quick decisions like in an emergency room.
Clinical documentation covers everything that takes place – from the patient visit, hospital admission and treatment to discharge and follow-up. Accurate patient records are crucial to manage the current hospital scenario as well as for the future reference. Information such as previous medical and surgical instances, procedures, social and family history, and medications and allergies are all taken into consideration in a medical scenario. So documentation errors pertaining to any of these areas would affect adversely future medical decision-making.
Medical transcriptionists need to be careful to avoid misinterpretations when documenting physician dictation. Areas where they commonly go wrong include spelling, capitalization, quotation marks, format of reports, spacing, and punctuation. When they come across names of drugs or medical conditions which sound similar, they should be alert enough to relate it to the context and transcribe it accordingly, failing which the patient could end up getting the wrong treatment with dire consequences. The healthcare provider’s reputation would be badly affected with accusations of medical negligence leading to litigation and malpractice lawsuits.
Such issues can be avoided with a professional medical transcription company handling the documentation task in compliance with the rules of American Association of Medical Transcription. In addition to a team of experienced medical transcriptionists, a reliable firm would have stringent quality checks by proofreaders and medical editors to ensure accuracy levels of up to 99%.
