The occupation of medical transcriptionists as defined by the U.S. Bureau of Labor Statistics (BLS), is to “transcribe medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries. Transcribe dictated reports and translate abbreviations into fully understandable form. Edit as necessary and return reports in either printed or electronic form for review and signature, or correction”. Medical transcription services have come a long way since their inception. The earliest records were surgery notes on papyrus in 1600 BC, according to Mobius MD. The 21st century sees medical transcriptionists playing a key role in the healthcare system by supporting physicians in the creation of electronic health records (EHRs).

Prior to the 1960s, physicians made their own notes on patient encounters, tests and operations. With the establishment of hospitals and other medical facilities in the early 20th century, a more formal method of creating patient records became necessary. The first medical note-takers were stenographers or medical secretaries who took physician dictation in shorthand and type out the notes on typewriters. The paper documents, which included handwritten notes and typed reports, were stored in individualized folders in filing cabinets. When a particular patient’s record was required, it would have to be located and delivered to the requesting physician.

The next phase in the history of medical transcription began when audio devices such as the portable recorder and tape cassette entered the scene. This laid the foundation for medical transcription as a formal profession. With audio devices, medical transcriptionists could record physician dictation and transcribe it at a later time.

The introduction of word processing machines in the 1970s improved transcription accuracy and speed. Advancements in technology transformed medical transcription as well. Dictation technology progressed from micro-cassettes to digital recorders to voice recognition. In 1978, the American Association for Medical Transcription (AAMT), now known as the Association for Healthcare Documentation Integrity (AHDI), was established as part of an effort to achieve recognition for and support the medical transcription profession. In 1999, the U.S. Department of Labor awarded medical transcriptionists their own job classification.

In the meanwhile, things changed dramatically with the advent of the internet. Physician dictation could now be sent via the web to medical transcription companies in other locations, either in the country or abroad, for transcription. The files were uploaded to and downloaded from an FTP server by medical transcriptionist and the healthcare provider.

In 2015, the introduction of electronic health records (EHRs) transformed the way clinical documentation is created. To ease documentation, EHRs come with cookie-cutter templates, drop-down lists, and check boxes that the physician can to document interactions and care at the patient encounter. With front-end speech recognition, providers need to edit/proofread their results to ensure the templated information is entered correctly and dictated text is accurately recognized by the technology. In other words, rather than easing things for the physician, the EHR made documentation more complex and physicians found it difficult to manage data entry with the patient sitting in front of them.

With physician stress and patient safety concerns associated with EHR usability issues, medical transcription outsourcing saw an uptick in dictation volumes as physicians turned to these clinical documentation specialists for support for editing and proofreading transcribed documents. Moreover, medical transcription software can safely and directly create an interface with the EHR. This allows the software to interpret data more effectively and eliminate any static information. With EHR implementation, the medical transcription process is required to comply with HL7 data requirements, which has increased the demand for advanced dictation software with speech recognition capabilities for more efficient data transfer.

Experience shows that speech recognition assisted clinical documentation comes with a higher rate of errors than records created with the help of medical transcriptionists. The technology’s ability to transcribe unfamiliar words and homophones such as their/there, terms, drug names, and phrases is limited. Also, the software tends to find it difficult to interpret different accents or dialects and dictation that lacks clarity. This means that the report generated will usually have errors and need substantial editing. With their busy schedules, physicians hardly have time to review their dictations. Fortunately, they can rely on an experienced medical transcription company to handle this task efficiently and in fast turnaround time.

To conclude in the words of Gary David, PhD in a For the Record Q&A: “Transforming dictated voice files into complete healthcare documentation is an amazing skill that involves a range of competencies. Ultimately, doctors do not generate revenue; documents generate revenue. When reimbursement occurs, it is based on the documents. When audits occur, they are based on the documents. Coding is done on the documents. Without quality documents, this process can break down”.

Physicians are focused on providing the best quality care supported by advanced technologies and innovative treatments. Medical transcription outsourcing allows clinicians to manage their EHR documentation tasks as they concentrate on their core activities. However, for their efforts to succeed, physicians need to partner with patients and encourage them to actively engage in their own healthcare. Today, patients have access to information, medical knowledge and their own health records. Building a successful doctor-patient partnership is crucial for achieving the best possible care outcomes.

Partnering with patients is about ‘patient activation’ which is different from ‘patient engagement’. “Patient activation emphasizes patients’ willingness and ability to take independent actions to manage their health and care,” according to Judith Hibbard, one of the first experts to define patient activation (www.patientengagementhit.com). This definition goes beyond ‘compliance’ which means getting patients to follow advice.

Patient activation means implementing strategies to encourage patients to become partners in their own care. Patients need to understand their role in the care process and get access to reliable healthcare information and digital health technology so that they have the knowledge and skills to make informed care decisions. Let’s take a look at some expert tips on building patient partnership:

• Providing Patients with Information about their Health: Patients should be made aware about their health conditions, treatments, and other health issues. They can be given educational material such as patient summaries, discharge instructions or written materials on new medications. In a 2018 study, researchers sent hypertension patients with low activation levels customized educational material about their conditions and potential treatment options. The material, in the form of a letter, identified the patient’s BP goal and provided suggestions to help them achieve it. The letter encouraged patients to initiate discussions with their healthcare provider about treatment options. The study, which was published in the Journal of the American Medical Association (JAMA), found that such clinician-led patient education can drive activation levels.
• Providing Health Information in Engaging and Accessible Formats: Patients should be provided with health information and explanations about care in simple language. All material need to be reviewed and simplified to ensure that the patient understands it. Information can be provided in formats such as print, mobile, apps and online channels. A Becker’s Hospital Review article recommends: “keeping materials simple enough for a sixth grader to comprehend and follow, healthcare professionals position themselves and their patients for success rather than failure”.
• Understanding and Documenting Individual Needs, Preferences and Goals: Partnering with patients to improve their care also means providing clear and useful information to patients, helping patients set goals, and develop strategies to maintain a healthier lifestyle. It is important to keep in mind that people expect their own needs, lifestyle preferences and desires to be considered in the care planning process. In person-centered care, the individual’s goals and preferences are taken into account when building the plan of care. The provider should document goals and interventions in discussion with the individual or their family. Patient engagement in setting goals has been found to impact their participation in and adherence to treatment as well as improve their health outcomes and quality of life. Patients should also be educated to support self-management.
• Encouraging Patient Question Asking: Patients should feel comfortable to ask questions about their health and related concerns. They need to know that asking questions is acceptable, and that their questions will be heard. Providers need to be ready to provide satisfactory answers on topics important to the patient. Encouraging patient question asking will make patients feel they are actively involved in any decisions that are being made about their care.
• Developing Programs to Encourage Adherence to Treatment: Adherence to treatment protocols, including medications and wellness plans is crucial for interventions to be effective. Making patients partners in their care calls for addressing barriers. Healthcare professionals need to first identify the barriers that prevent adherence and then leverage patient-centered strategies to overcome those barriers. Good adherence improves the effectiveness of interventions, leads to fewer hospitalizations and readmissions, and reduces the costs of care.

Building effective partnerships with patients and their caregivers/families takes time and commitment. Adopting advanced digital technologies and tools such as decision aids, appointment and medication reminders, automated appointment and follow-up scheduling calls can improve patient engagement. Patients can now view their medical records online. Viewing the notes can remind patients about what was discussed with their physicians during a visit and promote involvement and adherence. Providers can rely on medical transcription services to ensure complete, up-to-date and accurate medical records which can make all the difference to the quality and continuity of care.

Healthcare providers are well aware that documenting each patient’s condition and history of care is crucial and medical transcription outsourcing plays an important role here. To ensure proper care, the information about the patient must be communicated to other caregiver’s in the team.

An incomplete or inaccurate patient record can compromise care and shows:

• care was incomplete
• there were gaps, indicating poor clinical care
• lack of compliance with policies

Documentation errors (either commission or omission) result in improper medical advice being provided. By affecting care, poor documentation in patient clinical records can lead to allegations of negligence. It can also result in expensive, painful, and/or unnecessary diagnostic studies, billing mistakes, cause loss of reimbursement, and lead to charges of fraud and malpractice.

The first step to ensuring accurate and complete clinical documentation is recognizing the common errors that can occur and taking steps to prevent them.

• Confusing Statements from a Physician Related to Misinterpreted Dictation or Transcription Errors: It is critical that a reliable medical transcription service provider handles the task of converting physician dictation into text. Patient’s medications, procedures, and activities and ongoing developments in treatment need to be accurately documented for the reference of other caregivers. Certified and trained medical transcriptionists are familiar with even difficult medical terminologies and conditions, which among other things, is necessary for dictation to be transcribed accurately and promptly.
• Not Documenting Prior Treatment Events: Leaving out even small details of the treatment given to the patient across nursing shifts can have disastrous consequences. All incidents that occurred and treatment provided should be documented so that there is no room for doubt about the patient’s condition. The Nurse Service Organization (NS) recommends that nurses leverage hospital standard flow sheets in the patient’s EHR to document details of the treatment given to the patient.
• Not Placing an Operative Note on the Chart Immediately after an Operation is Performed: The operative note should be dictated and signed within 24 hours of operation/procedure. This document records the operation that the patient had, what was found during the surgery, and the surgeon’s post-operative instructions. Having this information in the chart is crucial for continuity of care when patient is moved into the recovery room or discharged.
• Medication Errors and Omissions: Medication errors can occur during prescribing, transcribing, dispensing and during administration. It is critical to record every medication given to the patient over the entire course of treatment-including the dose, route, and time of each administration. A 2017 study from the Pennsylvania Patient Safety Authority noted the EHR users are highly prone to making medication errors that negatively impact patient safety. Up to one third of mistakes were due to dose omissions, wrong dosage or over dosage, and extra dosages, according to the study. Many errors were also caused by improper documentation of medication instructions in the EHR errors. Errors were also caused when prescribers entered free-text instructions in the order comments field, which later went unnoticed by a pharmacist or nurse.
• Recording on the Wrong Patient Chart: Another EMR documentation mistake is entering orders in the wrong patient’s chart. Though uncommon, this mistake usually occurs when patients share the same name. It poses a major patient safety hazard. For instance, if a medication order is transcribed onto the wrong patient’s chart it will result in the medication being administered to that patient. NSO recommends assigning a different nurse to each patient when there are two or more patients with the same name. The patient’s wrist band should be checked before giving medications. Organizations should also implement a system of identifying patients’ names and medication records.
• Misplaced Documentation: According to AHIMA misplaced documentation concerns range from “data entered into the wrong field in an EHR to scrounging for missing pieces in a hybrid health record environment, misplaced information”. Common issues include misplaced progress notes, different providers using different terminology to explain the same condition, etc.
• Not Completing the Medical Record within the Specified Time: Each patient’s condition and history of care should be recorded in a timely manner. There are specific time requirements for completion of each element in the medical record:
  • History and Physical – completed and signed within 24 hours of admission
  • Post-op note – written immediately after surgery
  • Operative Note – dictated and signed within 24 hours of operation/procedure
  • Medical Record – should be completed within 7 days of discharge or outpatient visit

Strong documentation practices improve team communication and continuity of care. EHR documentation can be significantly improved through the use of medical transcription services. Skilled medical transcriptionists can ensure timely and accurate documentation to convey clinical information about patients’ diagnoses, treatment, and outcomes.