10 Best Practices for Cybersecurity in Medical Practices

17-April-2023 Rajeev Rajagopal Medical Transcription

Cybersecurity

All industries face cybersecurity threats that can compromise their sensitive data. In healthcare, cybersecurity issues can affect operations and put patient safety at risk. Cybersecurity breaches in healthcare occurred at an alarming rate throughout 2022. Healthcare providers and their EHR vendors and business associates like medical transcription companies need to strictly implement cybersecurity best practices to secure, monitor, and maintain protected health information (PHI).

Why Data Security is a Major Concern in Healthcare

Healthcare organizations are especially vulnerable to cyberattacks because they possess a lot of information of high monetary and intelligence value. As small medical practices have less resources to protect against cybersecurity incidents, they may be more vulnerable to hacking. In addition to patients’ protected health information (PHI) such as Social Security numbers, healthcare systems store financial information like credit card and bank account numbers, and intellectual property related to medical research and innovation.

Common threats to EHRs include phishing attacks, malware, and cloud threats. Stolen medical information is used to create fake IDs to purchase medical equipment or drugs, or to file a false insurance claim, according to Reuters. It is estimated that the cost of a breach in the healthcare industry is almost three times higher than any other industry.

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Ten Strategies to Improve Cybersecurity in Medical Practices

Medical practices can improve their cyber security by implementing the following measures:

Establishing a security culture: Medical practices must instill a security culture in all EHR users. Measures to protect PHI will be successful only if practices establish and implement stringent security policies. Users need to be sensitized to the importance of safeguarding information and trained on how to recognize and respond to phishing attacks, malware, and other cyber threats. A security-minded organizational culture is critical to guard against malware, data theft or business interruption. Practices should also assess their cyber security risks by regularly assessing employees’ security awareness, behaviors and culture. This will help identify any vulnerabilities in their systems.

Mandating multi-factor authentication: Practices should implement multi-factor authentication to add an extra layer of security to logins and minimize risk of unauthorized access to patient data. Multi-factor authentication combines two or more methods of authentication – passwords, biometric verification such as retina, fingerprint, or facial recognition, personal identification numbers (PINs), one-time passwords (OTPs), user location, and time-based authentication. A Physicians Practice article says that the easiest solution for small practices is to implement a password manager. In addition to generating and encrypting complex passwords, a password manager eliminates the need to remember or store multiple, unsecured passwords on the practice system.

Backing up and encrypting data: To ensure recoverability after a disruption, off-site data backup and encryption is vital. Data should be backed up in more than one location so that it would be available in case of hardware loss or failure. Encrypting the data ensures that even if it falls into the wrong hands, it cannot be read or accessed without a decryption key.

Implementing access controls: Access controls should be implemented to protect against known vulnerabilities. In fact, beyond using technologies, HIPAA requires covered entities to ensure that patient information is secure, accessible only by authorized personnel, and used only for authorized purposes. This will ensure that only authorized personnel have access to patient data.

Restricting and logging access to data: Implementing access controls supports data protection by restricting access to PHI and certain applications to only those employees who need access to perform their jobs. With access restrictions, user authentication will be required to access protected Practices should also log all data access. Tracking data access and usage will allow providers and medical transcription service providers to monitor who accesses what information, applications, and other resources, when, and from what devices and locations. If a breach occurs, an audit trail can pinpoint where it occurred.

Establishing data usage controls: Another best practice to protect patient information is implementing data usage controls. The first step is to identify sensitive data and tag it for the proper level of protection. Next, data controls should be implemented to prevent specific actions involving this confidential information, such as web uploads, unauthorized email sends, copying to external drives, or printing.

Regularly updating software: Medical practices should ensure that all software is updated regularly with the latest security patches and fixes. even if a computer that has all of the latest security updates to its operating system and applications, without anti-virus software, data can be stolen, destroyed, or defaced. It is important to use anti-virus software that provides continuously updated protection against the latest computer viruses and malware. Best practice is to ensure real-time protection by choosing the option for automatic updating overnight, restricting disruptions to practice operations (www.physicianspractice.com).

Preventing email compromises: Email compromises are one of the most common and damaging cybersecurity issues in healthcare, especially with the increasing use of remote options. Scam emails that seem to come from legitimate sources try to capture recipients’ attention and entice them to take “urgent” action by clicking on a link containing malicious code. One method that physicians can use to protect their email is by using sub-addressing or plus addressing. This technique allows you to ensure that the email is from a legitimate patient, partner, vendor, or external account. It involves adding a plus sign (+) followed by a unique identifier after your email address, before the “@” symbol. You can create multiple variations of your email address which will continue to direct to your original email account, but allows you to filter and track the message source and block unwanted emails. By automatically sorting incoming messages, filters can also help reduce junk mail.

Protecting mobile devices: Mobile devices, such as laptop computers, tablets, smartphones, and portable storage media can pose unique threats to information privacy. All devices, settings, and configurations should be properly managed with security measures such as:
- strong passwords and application data encryption
- Enabling the feature of remotely wiping and locking lost or stolen devices
- Preventing email malware infections
- Educating users on mobile device security best practices
- Ensuring that only applications meeting pre-defined criteria can be installed
- Installing mobile security software and keeping devices updated

Setting up a cyber security incident response plan: Medical practices should have a plan in place to respond to cyber security incidents, including steps to contain and remediate the incident and to notify affected individuals.

Outsource Medical Transcription to a HIPAA Compliant Company

Vulnerabilities or weak points in a healthcare organization’s security can lead to costly data breaches and associated detrimental impacts, from reputation damage to penalties from regulatory agencies. Healthcare providers should proactively identify by implementing the above-listed measures, improve their cyber security and better protect patient data. Practices should take care to outsource their transcription only to a HIPAA-compliant medical transcription company. Such companies have effective cybersecurity strategies in place to safeguard the electronic protected health information (ePHI) they handle from any kind of physical, administrative, or technical breach.

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10 Tips for HIPAA Compliance when using Mobile Devices

10-April-2023 Julie Clements HIPAA Compliance

HIPAA Compliance

With the growing number of smartphone users, the use of mobile technology in healthcare is widespread and increasing. People use mobile devices to gather healthcare information, download health apps, and engage with healthcare providers. Nearly 90% of physicians in the U.S. use smartphones to access electronic health records (EHRs), communicate with their team, search for information, and manage their schedule. Even as hospitals, clinics and other workplaces are permitting the use of smartphones, tablets and other portable devices, this has led to data security concerns. HIPAA-compliant medical transcription service companies prioritize patient data privacy and safety. HIPAA rules allow healthcare providers to use mobile devices to access ePHI in a cloud. Taking steps to meet HIPAA requirements when using mobile devices is essential to protect patient information.

Risks of Mobile Device Use in Healthcare

Verizon’s 2022 Mobile Security Index (MSI) report, which is based on a survey of 600 security professionals, found that nearly half of organizations had suffered a compromise involving a mobile device in the past 12 months (healthsecurityit.com). The report revealed that the use of mobile devices in healthcare came with several security risks such as:

Danger of lost or missing devices
Network threats
Device-based threats such as mobile malware
Public and home Wi-Fi policies
Improper IoT device security strategies
Poor app permissions
Poor password practices
Rise of ransomware and malware

Other security risks include outdated operating systems, lack of encryption for emails that physicians send or receive on mobile devices and insufficient Bring Your Own Device (BYOD) procedures. Providers may also accidentally disclose data when they share their unsecured mobile device with friends, family, or coworkers.

Meeting HIPAA requirements when using mobile devices can help covered entities and business associates including medical transcription companies keep personal health information (PHI) secure.

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Strategies for HIPAA Compliance on Mobile Devices

“Health care providers, other covered entities, and business associates may use mobile devices to access electronically protected health information (ePHI) in a cloud as long as appropriate physical, administrative, and technical safeguards are in place to protect the confidentiality, integrity, and availability of the ePHI on the mobile device and in the cloud, and appropriate BAAs are in place with any third-party service providers for the device and/or the cloud that will have access to the e-PHI,” says the U.S. Department of Health and Human Services (HSS).

Here are 10 ways to promote HIPAA compliance when using mobile devices:

Register all mobile devices with the organization and ensure that they are individually authorized to add, modify, remove, and access PHI.
Enable password/pin protection or biometric authentication on mobile devices to restrict access to sensitive patient data to authorized users.
Encrypt data on mobile devices. This will ensure that even if an unauthorized party tries to access the data, they will not be able to read it.
Use a secure messaging app. Using a secure HIPAA-compliant app specifically designed for healthcare communication will ensure that all data in transit and at rest is encrypted.
Follow all basic mobile security practices:
- Install security updates as soon as they become available. These updates usually come with important security patches to protect your mobile device from known risks.
- Avoid public Wi-Fi networks. Never access or transmit patient data using public Wi-Fi networks as they are often unsecured and can cause a data breach.
- Plug your mobile device only into secure systems (home computer, work laptop, etc).
- Use a mobile app scanner to find security vulnerabilities so that you can protect your device from them.
- Have a backup plan in case your device is lost or stolen. Use remote wipe to erase all patient data from your device if it is lost or stolen. This can help prevent unauthorized access to sensitive patient information.
Use a secure VPN. If you need to access patient data from a public Wi-Fi network, using a secure virtual private network (VPN) will ensure encryption of all data transmitted between your mobile device and the healthcare network.
Install firewall and anti-malware protection on all authorized and practice-owned devices. This is important to detect and remove malware from your devices.
Download only HIPAA-compliant apps. HIPAA compliant apps ensure the confidentiality of PHI (Protected Health Information), enable secure, seamless healthcare communications, and block unauthorized, fraudulent activities.
Train your staff on mobile device management policies Establish mobile device policies and train your staff on mobile device privacy and security awareness. Topics to discuss include risks and vulnerabilities when using mobile devices for work, how to secure the devices, how to protect and secure health information, and mistakes to avoid when using mobile devices.
Encourage reporting of security incidents: Even if an employee thinks that they may have simply misplaced their workplace device and that it will be found, the incident should be reported. Reporting the incident as early as possible as the cost and risks of PHI breach can be enormous and affected parties must be informed.

Though cybersecurity is a serious issue for healthcare organizations of all sizes, they can lower their vulnerabilities with the help of the right resources, thoughtful planning and expert support. Following these guidelines can help physicians utilize mobile devices in a HIPAA compliant manner and adhere to industry regulations and safeguards to protecting their patients’ sensitive health information. When it comes to EHR documentation, every healthcare provider must partner with a HIPAA-compliant medical transcription service organization to ensure patient data privacy and security.

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How to Make Radiology Reports More Patient-friendly

06-April-2023 Rajeev Rajagopal Radiology Transcription

Radiology Reports

Radiology reports are an essential element of patient care and communication between radiologists and referring physicians. Many radiologists rely on a medical transcription outsourcing company to deliver accurate and timely radiology reports. With the implementation of electronic health records (EHRs), patient portals, and the passage of the 21st Century Cures Act, patients can access their radiology reports. This makes patient-friendly radiology reports a necessity. Let’s take a look at what goes to make a patient-friendly radiology report.

Why Patients Need Access to Radiology Reports

Generally, radiology reports are written with the physician in mind and not the patient. However, allowing patients to access their health record is important as it can help them make more informed decisions about their healthcare. Online access also allows them to share their radiology reports with other physicians electronically, which could increase the safety, quality, and efficiency of care.

Diversified Radiology, a radiology group in Colorado, implemented a patient portal with interactive patient-friendly reports to help patients understand their imaging results. The effort was led by Jennifer L. Kemp, MD, FACR, who was at the time vice president and a body imaging subspecialist at Diversified Radiology. Up to 86% of patients who access their radiology reports with the tool report a positive experience.

“When patients better understand their radiology reports, they are more engaged in their healthcare. They are better positioned to advocate for the care they need when they have discussions with their physicians and are more likely to adhere to treatment recommendations if they understand the reasoning behind those recommendations. This means that, ultimately, patients will have better outcomes.,” said Kemp (as referenced by the American College of College).

While patient portals now facilitate patient engagement in care, patient understanding of radiology reports is crucial. Patient-friendly radiology reports are those with relevant information about the imaging study presented in a way that patients can easily understand.

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Tips for Writing Patient-friendly Imaging reports

Here are 5 tips for writing patient-friendly imaging reports:

Are easy to read and understand: The report should be clear and written in simple language that is easy to read and understand. As patients may not understand medical jargon or technical terms, avoid using them. The report should describe the results in plain language.
Clarify the reason for the test: The patient should understand why the test was ordered. Clearly explain the purpose of the study, its importance, and information that it provides.
Provide additional details and use visual aids: It’s important that the patient understands what is normal and what is abnormal. Using visuals and diagrams can help patients understand the findings better. For instance, in one study that discussed patient-friendly imaging reports, the patient was provided with his or her original image along with four additional images to simplify their understanding of the images. Also, describe how the findings relate to the patient’s clinical history and symptoms.
Avoid language that can cause anxiety: Avoid writing in a way that will make patients feel insecure and anxious. Many patients experience fear, anxiety, and worry as they wait for the results of diagnostic imaging tests. This is a completely normal and understandable feeling. Radiologists should ensure that they don’t use language that may alarm patients. They should focus on providing information that makes them feel more informed about their health in a reassuring tone.
Provide guidance on next steps: If there is an abnormal finding, the report should guide the patient on next steps in the Impression Section. For a potentially abnormal finding, RadiologyInfo.org notes that the radiologist may recommend:
Other imaging tests that can help better assess the finding or getting a follow up imaging test to relook at the finding after a period of time.
Getting a biopsy.
Combining the finding with clinical symptoms, laboratory test results, or with any other imaging studies that the radiologist interpreting the test does not have access to. This is common when patients have imaging tests done at different facilities or hospitals.

Patients could also be advised on consultations with other healthcare providers or lifestyle modifications.

If the radiology report does not answer the clinical question or there is a suspicious or questionable finding, more exams may be necessary. If they have questions, concerns or further questions, patients can contact their physician or radiologist.

Studies have recommended ways to design more patient-friendly radiology reports. In one study published in J Digit Imaging. (2021 Jun), the researchers said they provided definitions for any medical terminology and underlined these terms. The way the report was organized was also modified to make it easier for patients to read it. Different colors were incorporated to improve report navigation and increase understanding. The report also included a timeframe for treatment, instructions, resource information and a summary table with some general recommendations

The study found that the improved radiology report design could increase patient engagement, and that the enhancements could increase patient understanding of the report. “If the patient understands more about his or her report, this could decrease the time that physicians spend talking to patients about the report”, they wrote.

Providers need clear, concise, accurate and timely radiology reports that provide an objective assessment of the imaging findings. Correct information is essential to avoid misinterpretation of the images. Imaging reports should also include descriptions of the imaging findings, including the location, size, and characteristics of any abnormalities. Sufficient detail is necessary to enable referring physicians to make informed decisions.

Why Outsource Radiology Transcription

As radiology reports are important documents that provide vital information about a patient’s condition and treatment, they need to be transcribed correctly. Medical transcription outsourcing companies that specialize in radiology transcription can ensure accurate and timely reports that help healthcare professionals, such as primary care physicians, surgeons, and oncologists, to make informed decisions about patient care.

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Study: Electronic Health Records and Scribes can Improve Workflow in Allergy Practices

04-April-2023 MTS TEAM EHR Transcription

Electronic Health Records

The electronic health record (EHR) offers many advantages and have made documentation and provision of care easier for healthcare providers. As of 2021, nearly 4 in 5 office-based physicians (78%) and nearly all non-federal acute care hospitals (96%) had implemented a certified EHR, according to HealthIT.gov. EHR adoption has also increased in all specialties and many providers rely on outsourced medical transcription services to manage their documentation. The use of EHRs and medical scribes is an effective way to boost workflow and efficiency in the modern allergy and immunology clinic, according to a study published in Current Allergy and Asthma Reports in 2020.

Advantages of EHRs for Allergy Practices

The EHR system provides multiple benefits for allergy practices:

Offers a centralized storage location for patient health information in legible format
Provides quick access to patient records from anywhere, including remote locations
Ensures immediate and easy access to patients’ allergy history, medication usage, and treatment plans
Streamlines record-keeping processes
Interfaces with labs, registries, and other EHRs
Enables enhanced, rapid, effective communication
Reduces risk of medication errors and duplicate information
Improves care quality with enhanced decision support, clinical alerts, reminders, and medical information
Improves compliance in immunizations
Reduces costs and saves time searching for patient charts

The study authors noted that accurate and complete EHR documentation leads to improved patient charge capture and reduces billing errors. They also listed EHRs’ Allergy/Immunology specific attributes – recording allergy skin testing documentation; immunotherapy dose customization; administration, and documentation; incorporation of extract ordering, interface with pulmonary function testing and integrating questionnaires such as asthma control tests.

In addition to supporting providers, the EHR also provides many advantages for patients. The system facilitates appointment scheduling, reduces the need to fill out the same forms at each office visit, and sends notifications to providers about point-of-care data and important health interventions. E-prescriptions are electronically sent to the pharmacy. Patients can use the system’s patient portal to communicate with providers and receive electronic referrals for follow-up care with specialists.

However, despite their many benefits, in practice, EHRs can be time consuming to use on a daily basis. Providers point out that patient interaction can suffer when they perform EHR data entry during consults. EHRs also contribute to physician burnout.

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Study: Scribe Support can Ease EHR Documentation

According to the study authors, implementing various strategies to support EHR use can help allergy practices streamline workflow, improve job satisfaction, and reduce physician burnout. The study provided evidence to show that scribe support can significantly improve documentation and workflow efficiency in medical practices:

Reduces patient visit duration: A 2018 oncology study found that when physicians were provided scribe support in the clinical setting, there was a 12.1% decrease in the overall patient visit duration compared to previous clinic visits without scribes.

Increases productivity and reduces costs per patient: A large outpatient urology office 2017 study reported that productivity (measures as both office evaluation and management visits and total relative value units) significantly improved by bringing in scribes. Another comprehensive study of emergency physicians reported that presence of scribes was associated with productivity gains, as measured by the mean number of patients per hour per physician. Making use of a scribe was also associated with reduced length of patient stay and costs per patient.

Promotes optimal use of office staff and reduces physician stress: Research suggests that addition of scribes can promote optimal use of office staff and proper delegation, and improve job satisfaction, and reduce physician burnout.

Methods for integrating Scribes into Practice

Scribes can participate in the clinical setting in different ways:

Taking additional history before the provider sees the patient
Annotating/transcribing medical notes in the room with provider
Inserting the provider’s template note into the medical note (not in the patient’s room)
Inserting the provider’s dictated note into the medical note (as done by medical transcription outsourcing companies)
Using voice recognition

Allergists can choose the scribe integration method they are comfortable with based on the needs of their practice and their patients. While some physicians want to actively participate in the documentation process, many others prefer outsourcing medical transcription where the scribe takes on as much responsibility as possible to create accurate and timely EHR documentation. In fact, outsourcing comes with distinct advantages for busy allergists:

Accuracy: Experienced medical transcription service providers employ trained transcriptionists who are knowledgeable about medical terminology and allergy-specific information and can ensure a high accuracy rate of 99%.
Turnaround time: Quick turnaround time is crucial to ensure timely treatment and care for patients. By partnering with an expert, allergy practices can enjoy a TAT of 24 hours or less.
HIPAA compliance: Allergy practices should make sure to choose a HIPAA complaint transcription service that has proper security protocols in place to protect patient information.
Customized solutions: A reliable medical transcription company will adapt to allergy-specific templates and workflows to customize their services to meet the unique needs of allergy practices.
EHR integration: By seamlessly integrating with the allergy practice’s EHR system, a medical transcription service provider can ensure easy transfer of transcribed information.
Cost: Costs of allergy and sleep medicine transcription services can vary. Allergists can compare services and costs and choose the company that can provide value for money.

With the large number of service providers out there, choosing the right medical transcription company in the US can be a challenge. Allergists should carefully evaluate their requirements and make sure that the company they choose can provide accurate and timely allergy documentation solutions that meet their unique needs.

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How Human-based Medical Transcription Services improve Healthcare Communication, Care and Efficiency

30-March-2023 Julie Clements Medical Transcription

Healthcare Communication

Medical transcriptionists convert audio recordings of physician dictation into written notes that can be integrated into electronic health records (EHRs). A reliable US-based medical transcription company would have a team of trained and experienced professionals on board that can provide documentation solutions for various specialties. With the incorporation of speech-to-text technology in healthcare, providers can dictate into the electronic health record (EHR) and get clinical notes in real-time, decreasing time spent on documentation.

Despite the advances in voice recognition, human-based medical transcription services continue to play a critical role in the industry and improve healthcare communication.

Accurate and timely transcription of medical dictation: Medical transcriptionists can provide accurate transcripts of types of all types of medical records and medical documents including patients medical histories, examination reports, discharge summaries, chart notes, psychiatric evaluations, x-ray reports and more. They are well-versed in medical terminology and pharmaceutical aspects and also have superior typing and grammar skills. These skills enable them to deliver error-free transcripts. Review of machine-generated reports by medical transcriptionists also improves their accuracy. Service providers ensure that accurate transcripts are sent in quick turnaround time so that physicians and other healthcare providers have up-to-date information about their patient’s past and current conditions.

Improved collaboration among healthcare professionals: Interprofessional communication and collaboration plays a key role in healthcare. Complete, accurate and timely patient records enhance inter-physician communication and enable them to develop a proper treatment plan for the patient. Studies have shown that such collaboration can improve patient outcomes by reducing preventable adverse drug reactions and other medical errors^,optimizing medication dosages, and decreasing morbidity and mortality rates. A Robert Wood Johnson Foundation study of 20 hospitals found that by improving interprofessional collaboration between nurses and physicians, one hospital reduced its fall rate in half, cut average length-of-stay by 0.6 days, increased annualized bed turn by 20 percent, and increased discharges before noon by 20 percent.

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Gives physicians more time to focus on patients: Medical transcription outsourcing also streamlines workflows and frees up physicians’ time to focus on their patients. While EHRs can help reduce medical errors, when not used well they can strain the doctor-patient relationship. Time spent on the computer during the consultation takes away from the physician’s face time with the patient. With experts handling their EHR documentation tasks, healthcare providers can dedicate more time to patient care.

Reduces physician burnout: While the goal of EHRs is to make paperwork easier, a study by researchers from the University of New Mexico (UNM) that covered 282 clinicians reported that EHRs contribute to approximately 40 percent of clinician stress. The respondents appreciated the ability to access and update the EHR at their convenience, but expressed their dissatisfaction about how it led to after-hours EHR time. Using medical transcription services can help busy physicians save time and labor and ensure accurate and timely records of patient interaction and care.

HIPAA compliance: Reliable service providers will also help physicians ensure that reports comply with medico-legal concerns, policies and procedures. Ensuring the security, privacy, and protection of patients’ healthcare data is critical for all healthcare organizations and personnel. HIPAA compliant medical transcription companies understand the importance of maintaining patient confidentiality have various measures in place for this. This includes ensuring that protected health information (PHI) is stored on secure systems and protected with specific controls such as strong passwords, email encryption, intrusion prevention software, locking down USB ports, etc.

Customized solutions: Medical transcriptionists can provide quality reports in customized turnaround time ranging from 12-24 hours, which can help ease physicians’ workload to a large extent and importantly, avoid backlog. As they are knowledgeable about medical terminology, anatomy, and physiology, they can provide accurate documentation solutions for all medical specialists according to their requirements, even meeting sudden demands. Transcriptionists’ ability to understand the healthcare professional’s audio recording, correctly transcribe the information, and identify inaccuracies in the transcript is critical to preventing ineffective or even damaging treatment.

Quality control: Established medical transcription companies have stringent quality control measures in place to ensure the transcribed reports meet the highest standards of accuracy and consistency. The QA process includes three levels of checks by editors, medical editors and proofreaders for 99% accuracy. All transcriptions are also done using software such as the American Drug Index, Stedman’s Electronic Medical Dictionary and the complete range of Stedman’s books.

Quality, up to date information for patients: The regulations under the Health Insurance Portability and Accountability Act (HIPAA) provide individuals with the ability to access and obtain a copy of their health information. According to new federal rules, health care organizations must give patients unfettered access to their full health records in digital format. Patient access to medical records can enhance patient engagement and also improve patient safety and care quality. Competent medical transcription service providers can help ensure data quality in the EHR.

Flexibility: Partnering with a flexible transcription company is very important. Reliable service providers offer flexible dictation options such as digital recording and dictation to a toll-free number. They can also meet physicians’ stringent submission deadlines when needed. They are also in contact with the physician always so that they can make any changes to the records as required.

Cost-effective: Outsourcing healthcare transcription is also more cost-effective than doing it in-house. It can save the overall costs of equipment and infrastructure, salary, HR, benefits, and maintenance and training. With a dedicated third-party transcription provider, the benefits and savings far outweigh the risks and costs.

Human-based medical transcription services are a reliable option to maintain quality EHR documentation that improves collaboration among healthcare providers as well as among providers and patients. When care teams can collaborate easily and effectively, it can streamline workflows and drive improved patient outcomes. With the high levels of accuracy, consistency and timeliness that they provide, human-based transcription services allow health care professionals to focus their efforts on improving patient care.

We have extensive experience providing customized medical transcription services for individual physicians, clinics, and hospitals to medical management companies across the US. Our services are available for all major medical specialties and sub-specialties.

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What is the Role of Medical Transcription in Healthcare?

27-March-2023 Rajeev Rajagopal Medical Transcription

Medical Transcription in Healthcare

The role of medical transcription is rising in significance owing to the increased demand for healthcare services and consequent increase in documentation requirements. Medical transcription in healthcare focuses on ensuring reliable, accurate, and timely documentation of clinicians’ notes and dictations. Most physicians rely on professional medical transcription services for maintaining error-free medical records, and free up more time to focus on patient care.

Key Challenges of Medical Transcription in Healthcare:

Many physicians consider clinical documentation a burdensome task that reduces face time with patients, and drives burnout. Published in 2021, a study titled Analysis of Electronic Health Record Use and Clinical Productivity and Their Association with Physician Turnover evaluated data from 314 medical professionals in an effort to determine whether medical records and physician departure or resignations are related. They found that clinicians could spend up to 5.8 hours managing medical records for every eight hours of scheduled patient time.

Another cross-sectional study titled Medical Documentation Burden Among US Office-Based Physicians in 2019: A National Study published in 2022, analyzed office-based physician responses to the 2019 National Electronic Health Records Survey. The 1524 respondents represented 301 603 physicians nationwide. This study also revealed that documentation burdens US physicians. Most respondents indicated that documentation takes time from patient care.

While accurate medical records are essential for diagnosis and treatment, the electronic medical documentation workflow is burdened by bureaucratic requirements. Rigid documentation structures and strict administrative standards are making things extremely difficult for physicians. These challenges highlight the importance of clinical transcription in hospitals, where skilled medical transcriptionists can help ease documentation burdens, improve accuracy, and give physicians more time to focus on patient care.

Medical Transcription in Healthcare

How Medical Transcription Services Help

Medical transcriptionists are highly trained professionals who undergo extensive training to ensure they can perform their jobs well. They ensure that medical dictations or recordings are transcribed into accurate and reliable medical records while also abiding by HIPAA regulations. By delivering proper and timely information on a patient’s condition to physicians and other healthcare workers, transcription services support provider collaboration and quality care. By documenting, organizing, and capturing patient data, transcription services offer a simplified method for recording patient care. In addition to supporting patient treatment, these records have legal value as they can be cited in insurance and medical malpractice lawsuits.

Transcription services offer several benefits:

Improved Accuracy: When it comes to medical records, accuracy is crucial. Documentation errors can lead to erroneous diagnosis, ineffective therapies, and put a patient’s life in jeopardy. With a 99%+ accuracy rate guaranteed by its staff of human editors and cutting-edge speech-to-text technology, medical transcription services enhance care delivery and patient safety.

Timely Charting: Time is critical in healthcare settings. Patient treatment may be greatly impacted by the speed at which medical records are transcribed and made available. Healthcare providers gain rapid transcribing turnaround times. This makes it possible for physicians to quickly obtain the information they require, resulting in quicker and more efficient patient treatment.

Simplified Procedures: The administrative workload that healthcare providers face is always growing. By automating the process of turning spoken words into written text, transcription helps optimize workflows. This lessens the need for manual data input, reduces risk of clinician burnout, and frees up providers to devote their attention to patient care rather than administrative work.

Improved Information Security: The healthcare industry places a high value on confidentiality, and any data breach can have dire consequences. Sensitive patient data is always protected thanks to secure technology in transcription companies, which helps healthcare practitioners abide by laws like HITECH and HIPAA.

Multidisciplinary Communication: Integrative patient care requires efficient communication across various departments and expertise. Transcribing reports allows clinicians to quickly share them with involved parties such as nurses, specialists, and primary care doctors. This guarantees that all providers are in agreement with regards to a patient’s care plan.

Medical transcription services are integral to the efficient functioning of the healthcare system. They enhance accuracy and consistency in patient records, save time for healthcare providers, improve patient care, support EHR integration, and ensure compliance with legal standards. Proper formatting of medical documentation is crucial for clarity, consistency, and ease of use, and these services ensure that all records are accurately structured according to industry standards and provider preferences.

By outsourcing medical transcription for healthcare facilities, healthcare organizations can focus on providing high-quality patient care while benefiting from streamlined operations and improved documentation practices. Reliable providers have multilevel transcription quality assurance practices in place that ensure that all documentation meets the highest standards of accuracy and compliance, reinforcing the critical role of transcription in today’s medical environment.

Streamline your clinical documentation with precision and professionalism.

Common Medical Charting Errors to Watch Out for

23-March-2023 MTS TEAM Medical Transcription Company

Medical Charting Errors

Valid, accurate, complete, trustworthy, and timely electronic medical records improve the utility of clinical documentation, and enhance communication between healthcare providers. One of healthcare’s worst nightmares is wrong information in the medical record. As a medical transcription company in the U.S., we are focused on converting physician dictation to accurate text. However, healthcare providers can make mistakes that compromise the integrity of the medical records and patient safety. Multiple studies have highlighted the seriousness of the problem:

A John Hopkin’s study suggested that medical errors account for more than 250,000 deaths per year in the U.S.
According to a poll by the Kaiser Family Foundation, 21 percent of respondents reported that they or a family member noticed an error in their EHR.
In a survey study of patients published in in 2020, 1 in 5 patients who read a note reported finding a mistake and 40% perceived the mistake as serious.

Even small errors or omissions in a patient’s medical record can result in serious patient injuries and harm as well as have legal consequences for the provider.

Common Medical Charting Errors

Let’s take a look at the common medical charting errors, why they occur, and how to avoid them.

Incorrect medical history: Wrong medical information in patient records is a common error. While some errors are harmless, others can be worrying or fatal. CNBC references a leading health IT company estimates that about 70 percent of records have wrong information. The report was on a young student who found that her medical record stated that she had two children when she had never been pregnant! Another study published on JAMA Open Network said that a patient who mentioned chest pain, tightness, and palpitations found all these marked as negative in the chart. In other cases, the provider did not document the most important reason for the visit.

The history is the key component of patient assessment and considered the most important part of the patient-physician interaction. Improving patient history taking practices is crucial to obtain the correct information and drive patient collaboration and trust.

Inaccurate medication instructions: The five “rights” of medication administration are: right patient, right medication, right time, right dose, and right route. Inaccurate documentation of the patient’s symptoms, diagnosis, or treatment can lead to inaccurate medication instructions. Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors.

Drug administration prevention strategies include standardized communication in electronic health records (EHRs), standardized product labeling, and drug information resources to alert “look alike, sound alike” drug names and using the correct expression of numeric doses.

Documenting orders in the wrong chart: Factors that lead to orders being wrongly documented in the chart include patient misidentification during registration, difficulty in locating the patient’s EHR, existing duplicate medical records, and typos. Patient misidentification or patient ID errors are among the most common errors in health care. A 2018 Pew Charitable Trusts report found that one out of every five patients may not be completely matched to their medical records.

Patient ID errors can lead to patients getting the wrong treatment, which can have grave consequences. The issue can be avoided with the right identification analyses, workflows, and safeguards in place. Healthcare organizations should identify the root causes of patient misidentification, understand the reasons or contributing factors behind noncompliance, and take steps to correct the problem. Experts recommend having a reliable patient identification system throughout the states.

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Use of inappropriate abbreviations: For physicians and nurses, using abbreviations can be a real time-saver during documentation. Abbreviations facilitate quick charting, but providers and their patient are at risk if it’s not done correctly. Chances of misinterpretation are high with medical abbreviations. For instance, if a nurse misinterprets “mg” as “milligram”, when it actually means “microgram”, it can lead to serious problems for the patient. Further, trying to figure out what the correct interpretation can waste precious time.

There are many error-prone abbreviations in healthcare. The ISMP National Medication Errors Reporting Program (ISMP MERP) allows subscribing healthcare institutions to report and track medication errors in a standard format. The program has published a list of abbreviations, symbols, and dose designations that have misinterpreted and involved in harmful or potentially harmful medication errors. Best practice is to avoid unnecessary abbreviations and use only abbreviations you are certain about and avoid those you don’t know.

Not documenting important information: When a healthcare professional does not document important information about a patient’s condition or treatment, it can have serious consequences, unless the problem is discovered and corrected in a timely manner. For instance, the treatment history should include:
- Chief complaints
- History of illness
- Vital signs
- Physical examination
- Surgical history
- Obstetric history
- Medical allergies
- Family history
- Immunization history
- Habits include diet, alcohol intake, exercise, drug use/abuse, smoking, etc.
- Developmental history
Leaving out any of these elements can result in incomplete information in the medical record. Likewise, a physician may forget to document the results of a laboratory test. Incomplete documentation errors in healthcare can affect care. To prevent this issue, the Medicare Claims Processing Manual says “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

Transcription errors: Transcription mistakes can occur with speech recognition (SR) software. Speech recognition may reduce the clinical documentation burden, but one study found an error rate of more than 7% in SR–generated clinical documents. Researchers have found potentially significant error rates in software-transcribed emergency medicine and radiology notes, according to a study published by the Patient Safety Network (PSNet). That’s why manual editing and review of machine-generated documents is essential.

Careless use of copy-paste: Another charting mistake relates to the use of the EHR system’s copy-paste function. Many physicians find EHR data entry cumbersome and time-consuming, and try to save time by copy-pasting patient information from previous encounters into the current encounter’s notes.

Medical documentation is an essential part of patient. Errors in documentation can lead to leading to patient injury, including delays in treatment, misdiagnosis, and even death. Healthcare providers to be aware of these errors and take steps to avoid them. Partnering with a professional medical transcription company is an ideal way to reduce the risk of documentation mistakes and promote clear, legible, compliant and timely charting to support superior patient care.

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5 Ways Voice Recognition in Healthcare Is Improving Outcomes

20-March-2023 Julie Clements Medical Transcription Outsourcing

Voice Recognition

Speech recognition technology (SRT) or voice recognition in healthcare is transforming how clinicians document, access, and manage patient information in today’s fast-paced medical environment. By converting spoken words into accurate clinical data, speech recognition technology in healthcare reduces administrative workload, improves documentation speed, and enhances care delivery. When combined with reliable medical transcription services, voice recognition helps healthcare organizations streamline workflows, maintain accuracy, and support better patient outcomes.

The global speech and voice recognition market is experiencing rapid expansion, with its value expected to rise from $11.21 billion in 2022 to $49.79 billion by 2029, reflecting a strong 23.7% compound annual growth rate during the forecast period. During the COVID-19 pandemic, speech and voice recognition tools proved especially valuable—for instance, Apple’s Siri supported patients by guiding them toward telehealth applications via the CDC’s COVID-19 assessment resources. Further advancing this technology, Google LLC introduced its Speech-to-Text API in April 2022, enhancing voice-based user interfaces through neural sequence models that improve recognition accuracy across 23 languages and 61 supported locales, reinforcing the growing role of AI voice technology in healthcare.

Understanding Voice Recognition in Healthcare: What It Is and Why It Matters

Let us look at the impact of voice recognition on patient care. Voice recognition technology analyzes speech patterns to accurately interpret spoken words and associate them with specific speakers. Beyond basic speech-to-text functionality, it can identify speakers, analyze language proficiency, and even detect emotional cues within speech, making it a highly advanced and impactful technology.
In healthcare, voice recognition has become especially valuable for managing administrative and clinical documentation tasks. By enabling hands-free interaction and real-time data capture, voice-enabled systems powered by medical voice recognition software enable healthcare professionals to:

Quickly search patient records and clinical databases
Dictate notes and recordings directly into EHR systems
Schedule appointments and follow-ups with ease
Accelerate diagnosis while reducing documentation errors
Support remote care by minimizing the need for in-person interactions
Enhance patient engagement by simplifying access to medical records and prescription refills

Key Ways Speech Recognition Is Advancing Healthcare Delivery

Different Ways Speech Recognition Technology is Enhancing Healthcare

SRT is enhancing the delivery of healthcare in many ways:

Reduces the need for written documentation: SRT can be used as a tool for communication between healthcare providers and patients. It enables patients and their families to communicate clearly face-to-face with healthcare providers. Patients who have difficulty using their hands due to illness or injury and cannot send mails or messages to their healthcare provider can use SRT to communicate instead. Other patients may have problems reading or understanding prescriptions and other information presented to them on paper. Voice recognition makes communication easier for these patients.
Improves care and healthcare staff efficiency: In addition to being useful for patients and residents, voice interactive technology is useful for senior and post-acute care staff, notes a HealthTech article. Staff can use it to triage patient or resident needs and medication requests, instead of physically going into a room to communicate. Overall, voice recognition can reduce the challenges of information exchange and data collection and free up healthcare staff to focus on core tasks and improve efficiency.
Helps with language barriers: Leading voice recognition software supports automatic real-time translation for multiple languages, and transcription and translation for 60 languages. This makes SRT quite useful for patients who cannot communicate traditionally.
Captures the patient’s voice: Voice data can provide valuable, valid and reliable evidence about how the patient is doing. Voice notes captured during consultations is an important source of voice data in healthcare. These recordings of patient voice in healthcare can be organized and used for future medical references, or to know the reasons behind positive and negative feedback. According to a Forbes article published last year, “The patient’s voice will become a source of data not altogether different than blood pressure, temperature and other vital signs”.
Documentation: Voice recognition technology for medical documentation has transformed the way clinical notes are created. Physicians simply dictate their notes, and the system records and converts spoken words into text.

Voice Recognition and Medical Documentation

One of the most significant uses of speech recognition technology in the healthcare industry is in the automation of the medical documentation process. Clinicians are using the technology to speed up the transcription of patient information. The technology converts words into text in real time. Voice recognition software can transcribe encounters three times faster than manual typing into the EHR. Reports say that it can significantly reduce physician burnout and free up a couple of hours a day for a provider who sees twenty to thirty patients a day (healthcareitnews.com).

The latest AI scribes use voice recognition, machine learning, natural language processing, and other models to automate clinical documentation. For instance, DeepScribe works as follows:

listens in on a patient encounter via the provider’s cell microphone
creates a high quality recording
AI uses natural language processing to autonomously extract the medically relevant information from conversation
produces a complete medical note and integrates it directly into the relevant EHR fields

According to DeepScribe, with their AI-powered tool, clinicians no longer have to endure the burdens of medical documentation or even dictate during their encounter or after. The provider can just speak naturally during the encounter, and DeepScribe will take care of the rest.

Despite the advantages of voice recognition to automate clinical documentation, medical transcription outsourcing continues to be relevant. Certified medical transcriptionists review and oversee the transcripts generated by voice recognition technology by carefully listening to the original dictations and comparing them against the automated output. They identify and correct errors caused by misinterpretation, accents, difficult medical terminology, or background noise, ensuring the final medical reports are accurate, complete, and clinically reliable.

Many providers are using a hybrid approach or combination of automated and manual methods, according to Dolbey. This involves filling some text fields or checking some boxes manually and using voice recognition to complete the rest of the documentation. It could also involve using speech recognition to draft the documentation and using medical transcription services to edit and improve its accuracy.

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4 Best Practices to Maximize Efficiency in Dentistry Transcription

13-March-2023 MTS TEAM Medical Transcription

Dentistry Transcription

Even with advanced tools, dental transcription can feel slow and repetitive. The challenge lies in complex clinical terminology, tight time constraints, and the constant demand for accuracy. Improving dentistry transcription efficiency is a major challenge for dental professionals who must balance patient care with detailed documentation. Incomplete notes, misinterpretations, and delayed records can affect both workflow and patient outcomes.

This is where technology is making a real impact. AI-powered solutions are transforming traditional processes by delivering faster, more accurate documentation. With the support of advanced medical transcription services, dental practices can streamline workflows, reduce manual effort, and ensure consistent, high-quality records, allowing providers to focus more on patient care rather than paperwork.

Importance of Dentistry Transcription Efficiency

Accurate medical records are the foundation of every successful dental practice. These records include a patient’s medical and dental history, treatment plans, progress notes, prescriptions, and post-treatment outcomes. For dentists, these records are more than just documentation, they serve as a roadmap for patient care, ensuring dental documentation accuracy at every stage.

Comprehensive records enable dentists to track oral health over time, detect emerging issues, and make informed decisions regarding future treatments. They also play a key role in ensuring legal protection, streamlining insurance claims, and maintaining transparency in communication with patients.

For instance, when a patient visits for a follow-up appointment, having detailed and up-to-date records ensures that the dentist can easily review past treatments and recommend the best course of action. Without accurate records, there’s a higher risk of misdiagnosis, repeated procedures, and reduced continuity of care. This highlights the growing importance of effective patient record management in dentistry for long-term clinical success.

Challenges of Record-Keeping in Dentistry

Maintaining accurate records is not easy in a busy dental environment. Several factors make performing documentation in-house a time-consuming and complex task:

Complex Dental Terminology – Dentistry involves specialized terms, codes, and abbreviations that must be accurately transcribed. Errors or inconsistencies can lead to miscommunication or billing issues.
Limited Time for Documentation – Between patient appointments, administrative tasks, and treatment procedures, dentists often struggle to find time for detailed record-keeping.
Regulatory Compliance – Dental practices must adhere to strict data privacy and security standards, including HIPAA compliance. Inadequate documentation can lead to compliance breaches or legal complications.
Technological Barriers – Managing and updating digital records through electronic health systems requires both accuracy and speed, which can be difficult without proper transcription support.
Copy-and-Paste Entries– The frequent and injudicious use of copy-and-paste functions, macros, templates and other tools by dentists is reported to be a major concern. While copy-and-paste and using standardized text are useful for certain aspects, a cloned entry from a previous record can pose significant dental-legal risks.

These challenges highlight the need for specialized support systems like professional transcription services that streamline record creation and ensure accuracy. Many practices now opt to outsource transcription to reduce administrative stress while maintaining precision and compliance.

Role of AI in Dentistry Transcription

AI in dental transcription is transforming the way dental practices handle documentation by converting spoken notes into accurate, structured reports in real time. These advanced systems are trained to understand complex medical and dental terminology, ensuring that every diagnosis, treatment detail, and clinical observation is captured with precision.

In dental practices, AI transcription tools can efficiently manage a wide range of documents, such as:

Patient history reports
Periodontal and orthodontic notes
Radiology reports
Surgical and post-operative summaries
Referral letters and insurance documents

By enhancing dental documentation accuracy, AI-powered transcription enables dentists to track oral health over time, identify potential issues early, and make well-informed treatment decisions. It also supports smoother insurance processing, ensures legal compliance, and improves communication between patients and healthcare providers. Ultimately, AI-powered transcription enhances workflow efficiency, improves accuracy, and allows dentists to focus more on delivering quality patient care.

Dental Transcription Services

Boosting Dental Transcription Efficiency

If you are planning to have in-house staff do the transcription, here are 4 effective ways in which you can improve efficiency of your dentistry transcription:

Use the right medical transcription software: The right software can help improve the efficiency of medical transcription.
- Such software is specifically designed for dental practitioners to achieve the highest efficiency in dental and clinical documentation.
- You can choose software that is compatible with your EHR, and it will enable you to keep your dictation document in sync with your EHR.
- Medical transcription software comes with voice capture and speech recognition capabilities. So, the transcriptionist can more easily and accurately capture the dentist’s dictation.
- The software supports a variety of audio and video file formats.
- Other significant features available are medical spell checking and dictionaries.
- Once the transcript is quality-checked and approved, the software can make the transcript available in the desired format. It can be synchronized to the dentist’s computer or handheld device, or sent for printing.
Use state-of-the-art cloud-based computing: This facilitates safe storage as well as access of data. Cloud technology ensures safety with document transfer and helps meet HIPAA compliance when sending, sharing or retrieving voice and data files over the Internet. Moreover, this technology is scalable in keeping with your changing demands. Transcription becomes simpler to manage and carry out, and this increases the efficiency of your dental transcription. Since the cloud provider offers the necessary resources, dental practices get valuable cost savings and excellent ROI.
Use artificial intelligence for efficiency and accuracy: AI or artificial intelligence is increasingly used in all business sectors for its many advantages. AI-assisted medical transcription can produce more accurate transcripts faster while offering scalability for busy practices.
Take measures to improve your TAT:
- AI medical transcription tools convert voice recordings into structured text instantly. This eliminates manual typing and significantly reduces the time required to complete documentation.
- With automation in place, there is less need for tools like word expanders, macros, or repeated audio playback, which were previously used to speed up transcription.
- While AI handles the bulk of transcription, professionals review the transcripts to ensure context, clarity, and clinical accuracy are maintained.

Key Benefits of Medical Transcription Services for Dentists

From improving efficiency to reducing errors, professional medical transcription services help dental practices maintain high-quality documentation while enhancing overall patient care.

Improved Documentation Accuracy
Medical transcription services guarantee detailed and precise documentation, which minimizes errors in treatment notes and ensures all critical patient information is properly recorded.
Time Efficiency and Reduced Workload
By outsourcing transcription tasks, dentists can dedicate more time to patient care rather than administrative duties. This improves productivity and reduces stress related to record-keeping.
HIPAA-Compliant Data Handling
Transcription providers follow strict security protocols to maintain confidentiality and ensure compliance with healthcare privacy laws, protecting sensitive patient data.
Fast Turnaround and Accessibility
Quick turnaround times mean that dentists have access to updated patient records whenever needed, which supports timely decision-making and enhances clinical efficiency.
Integration with Dental Practice Software
Many transcription services are compatible with electronic dental record (EDR) systems, allowing seamless integration and easy access to digitized documentation.
Cost–Effective Solution
Outsourcing transcription is often more economical than hiring in-house staff, helping dental practices reduce overhead costs without compromising quality.

Integration with Electronic Health Records (EHRs)

The integration of transcription into EHR systems has significantly improved the clinical transcription workflow in dental practices. AI-generated transcripts are seamlessly uploaded into digital records, making patient data centralized, searchable, and easily accessible during consultations.

This digital approach reduces errors commonly associated with handwritten notes, such as misinterpretation or illegibility. It also supports better collaboration among healthcare providers, especially when patients require coordinated care from specialists like orthodontists or oral surgeons.

Overall, combining AI medical transcription with EHR systems streamlines the clinical transcription workflow, enhances data accuracy, and improves the quality and efficiency of patient care.

Efficient documentation plays a key role in improving workflows and time management within a dental practice. By leveraging medical transcription services, dentists can reduce administrative burden, eliminate backlogs, and focus more on patient care. This not only ensures well-organized records but also supports improving productivity in dental transcription processes.

Accurate and structured records also simplify communication with insurance providers, leading to faster claims processing and fewer rejections. With fewer documentation errors and better compliance, dental practices can operate more smoothly. Overall, combining expert transcription support with digital systems helps create a more efficient, reliable, and patient-focused practice.

Reduce Charting Time with Efficient Dental Transcription Support!

6 Ways Physicians can Improve Dictation Efficiency

09-March-2023 Julie Clements Medical Transcription

6 Ways Physicians can Improve Dictation Efficiency Clear, accurate and timely medical records are essential to support patient care. Physicians need to relay precise and accurate data to the other members of the patient’s care team. Dictated reports are usually sent to a third party for transcription. One problem that teams in US based medical transcription companies face is unintelligible reports due to poor dictation. Transcriptionists say that record quality and timeliness depend to a large extent on the quality of the audio recordings they receive from physicians. Let’s take a look at that factors that impact dictation quality and how physicians can improve dictation efficiency.

Reasons for Poor Dictation Quality

Physicians prefer dictation to taking notes when they are face-to-face with their patients. Dictating frees them to focus on each patient, allowing them to efficiently carry through and conclude each visit, and prepare to see the next patient. Dictation within the exam room reduces the time spent on recording care. However, there are many factors that can detract from dictation quality and make it challenging for medical transcription service providers to deliver accurate notes from the audio sent to them:

Workload: Busy physicians may dictate on the go or during their busy schedule. This can lead to them dictating too fast and inadvertently missing out critical information when documenting a procedure. Clarity is a major problem with a fast dictation.
Background noise: Physician dictation doesn’t always take place in a controlled environment. Physicians have a tendency to multitask. They may dictate while eating or chewing gum, or when they are driving or in a crowded room, which can all affect dictation quality. Even if they dictate in a hospital setting, noise created by patients, family members, or medical assistants can affect the dictation recording process.
Lack of organization: This is another key factor that can impact dictation quality. Not being organized when reporting a case can lead to something important being left out, especially if there are interruptions during the dictation process. In addition to procedural information, dictators who lack consistency can leave out even patient demographic information.
Speech patterns: Mumbling can happen when clinicians dictate the same procedure several times during the day. In fact, mumbling is one of the most common dictation problems for medical transcriptionists. Speech patterns can also be impacted when the clinician is tired, and result in whispering.
Heavy accents: Heavy accents may a problem when it comes to medical dictation. Processing the speech of people with accents can be a challenge for both human transcriptionists and speech recognition software.

Dictation accuracy and sound quality are crucial because decisions about treatment and ongoing care are based on information in the chart. Poor dictation habits and bad audio can:

affect quality of patient care and safety
result in incomplete coding due to reports with blanks of missing information
cause delays in care
lead to delayed reimbursement
impact transcription accuracy and turnaround time

A reliable medical transcription company will not fill in a report that is incomplete. Instead, they will send it back to the physician for clarification. This causes delays throughout the entire system and significantly increases the time needed to create a complete and accurate report.

Six Best Practices to Improve Clinician Dictation

The correct workflow and practices can significantly reduce the time that clinicians spend on dictation. Here are 6 effective ways to avoid dictation-related problems:

Physician education: Industry experts say that education is the best way to improve dictation practices (radiologytoday.net). Communicating the importance of high-quality dictation can influence physician by showing them how it supports patient care, billing, and even legally. Beginning a dictation session with proper patient identification is a helpful practice. Informing radiologists about the importance of entering the correct numbers at the beginning of a dictation session will ensure that the correct work type and patient demographics are used. Correct documentation will eliminate the need for clarifications and improve radiology transcription turnaround time.
Dictating in the presence of the patient: Dictating in front of the patient is recommended. This will not involve any extra time. It will also improve the accuracy of the history and physical as you can ask for clarifications. Patients can get a better understanding of their condition and treatment recommendations. Improving the quality of your records can improved reimbursement, and provide malpractice protection and patient care. Patient-present dictation also increases patient satisfaction as the physician is spending more time with the patient.
Organize your thoughts: To improve dictating, consider making brief notes or jotting down keywords in advance. This will help you organize your thoughts during dictation and help you include the right information in your narrative.
Location is important: As we have seen, a noisy dictation environment is a common problem. Even in the hospital, quality is a major concern for dictation done at nurses’ stations where background noise can be overwhelming. As far as possible, dictate in a quiet setting.
Use speech-to-text: With speech recognition (SR) software, physicians can dictate and immediately review the results of the charting session. The technology offers the best of both worlds – physicians can continue to dictate while avoid typing and quickly document medical history, symptoms, treatment plans, and other observations. Studies suggest that SR can improve overall process efficiency when used for dictation tasks such as reporting radiology or pathology results. Accuracy of machine-generated transcripts can be improved by getting them checked by an experienced medical transcriptionist.
State numbers and homophones clearly: Numbers and other numerical concepts appear throughout clinical notes and signify the value reported to indicate the function of cells, glands, hormones or organs in the body. When dictating numbers, use the appropriate form. As some digits can be easily confused when dictated, for e.g., 15 and 50, spell them out. This is especially important for medication dosages, where errors can lead to the wrong treatment. Repeat or spell out dosages precisely. Likewise, if not handled properly, homophones or same-sounding words can make a report inaccurate and useless. If you use ‘their’ and ‘there’, spell them out.

Dictation quality is crucial when it comes to documentation quality. Established medical transcription companies guarantee an accuracy level of 99 percent and custom turnaround time with good quality dictation.