Accurate, timely and reliable medical reports are crucial for proper patient care as they allow physicians to make the right decisions at the right time. Medical reporting errors can have fatal consequences. Clear, legible medical records promote proper patient care and are the physician’s greatest defense against allegations of negligence. Both clinicians and the medical transcription service provider play a key role when it comes to ensuring quality reporting.
Here are some recommendations to help practitioners prevent medical transcription errors:
- Clear recording of dictation: Today, medical transcription service companies transcribe physician dictation into the electronic health record using advanced interfacing systems. If speech recognition systems are used, they provided clear edited versions of the transcripts. Good dictation practices are necessary to ensure the accuracy and integrity of the reports. Physicians need to dictate at a normal pace and using a good quality digital recorder or other system that the transcription company supports. Using a microphone with a noise reduction filter would allow for high speech recognition accuracy.
- Spell out complex words: A professional medical transcription company would undoubtedly have experts on the job, but it is important just the same for physicians to take care when using complex terms or the names of medications. Physicians can spell out difficult or unfamiliar terms to reduce the risk of transcription errors.
- Provide precise and complete information: Providing precise, comprehensive information is necessary to avoid misunderstandings and errors. For instance, misinterpretations and inaccurate reporting of drug dosages can be prevented if the physician fully puts down instructions about how to administer the drug and avoid using abbreviations for dosage units or for the name of the drug.
- Use a standard format for dictating reports: Physicians should stick to using a standard template or checklist for dictation. This will ensure that no information is missed. It will also be easier for the transcriptionist to follow.
- Ensure timely medical reports: It has been found that procedure reports or discharge summaries that are dictated long after the event are a drawback for hospitalists. Reports that are dictated too long after a procedure would lack credibility in the event of litigation as it will be difficult to determine whether or not a medical complication occurred due to negligence.
- Review dictated reports properly: Unreviewed reports that contain errors or omissions can present a major problem for physicians in litigation. Physicians should review the transcripts of operative, History and Physical, consultation reports, and others to ensure their accuracy. Failing to do so would be considered negligence in a malpractice case.
- Outsourcing medical transcription to an experienced service provider: With the rising influx of patients and complexities of care, most physician practices now outsource their transcription work. Partnering with an experienced medical transcription company is crucial for good, timely documentation.
On their part, medical transcription companies need to use transcriptionists who are well-trained, have good language skills, and are familiar with medical terminology, procedures and other details necessary to provide accurate reports. They should have stringent proofreading policies and quality control measures in place to deliver quality documentation in custom turnaround time.