This year, National Medical Transcriptionist Week will be celebrated from May 17 to 23. Sponsored by the Association for Healthcare Documentation Integrity (AHDI), this event mainly aims at recognizing and celebrating the contributions of healthcare documentation specialists (HDSs). The spotlight will also be on the importance of verifying the accuracy of medical records and building awareness about speech recognition errors.
According to the AHDI, healthcare documentation specialists play a critical role in the accurate capture and documentation of patient encounter information. They partner with HDSs to develop their workforce continually, offer and promote the significance of becoming credentialed and advocate on patients’ behalf. As per AHDI, documentation specialists as essential members of the healthcare team can ensure patient safety through complete and accurate documentation.
Critical Role of Healthcare Documentation Specialists
Healthcare documentation specialist is an umbrella term given to medical transcriptionists, speech recognition editors, QA specialists and others involved in clinical documentation and data capture. Their knowledge is vast and includes pharmacology, human disease process, anatomy and physiology and various technologies that are used to capture healthcare data. They also understand the requirements of HIPAA and HITECH, workflow and processes. Serving as the guardians of data integrity, healthcare documentation specialists help clinicians produce accurate, secure and meaningful health records that will help ensure quality patient care and safety. HDSs take account of information-rich narrative, which is the keystone in clinical decision making and coordination of patient care.
HDSs possess leadership, management and medical knowledge which can be utilized in different areas of a healthcare organization. Blending their expertise in data integrity and medical language, clinicians can optimize their time, coding and revenue, and reinforce and strengthen the data governance strategy. Documentation specialists provide front-line document risk management, monitoring documents for:
- Wrong patient/wrong content (demographic mismatches)
- Wrong provider name
- Wrong dates of service
- Incorrect work types
- Medication dosage errors
- Right/left, male/female inconsistencies
- Medical contradictions
- Other missing elements and speech recognition errors
The crucial role of HDSs in facilitating successful transition to speech recognition technology and the EHR is important as well. They are knowledgeable in identifying important quality issues around changes in healthcare documentation process. Speech recognition technology (SRT) works best if there is an expert HDS, who accurately captures whatever is being dictated without making structural or major formatting customization changes. Even though customization is activated, SRT software may produce errors due to the clinician’s mistakes or noisy environment while recording. An expert HDS can easily identify such errors and ensure accurate documentation.