Medical Abbreviations that a Transcriptionist Should Know

02-April-2015 Rajeev Rajagopal Medical Transcription

Most often, physicians use abbreviations when they are dictating as it saves time. Knowledge about medical abbreviations is therefore quite critical in the medical transcription process. Only medical transcriptionists who are well-versed in these abbreviations can produce a quality report in the specified turnaround time. Knowing about commonly used abbreviations helps them figure out which one is relevant in a particular context. This is necessary to avoid misinterpretation of the abbreviations, which may lead to errors in the final report and affect patient care.

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Here are some commonly used medical abbreviations which that professionals handling transcription should know about:

A&O- alert and oriented
BKA- below-knee amputation
CBD- common bile duct
CPS – Child Protective Services
DC- discharge OR discontinue
EKG – electrocardiogram
FNA – fine needle aspiration
GCS – Glasgow coma scale
HIV – human immunodeficiency virus
IBS- irritable bowel syndrome
JVP- jugular venous pressure
LLQ- left lower quadrant
MCL- medial collateral ligament
NICU – neonatal intensive care unit
OT – occupational therapy
PCP -primary care physician
RBBB – right bundle branch block
SFA – superficial femoral artery
TM -tympanic membrane
UPJ- ureteropelvic junction
VF- ventricular fibrillation
WDWN – well developed, well nourished

Even when the dictator mentions the whole term, a skilled transcriptionist would be able to correctly specify its abbreviation in the report. This would speed up the process and help avoid lengthy, complex sentences, improving the documentation quality, clarity and turnaround time. However, it is important to know when abbreviations are acceptable for use in medical transcription and when they are not. Knowledge about the rules and formats for lower case, upper case and mixed case abbreviations is also necessary to avoid misinterpretations and errors.

Also Read: Avoid Misinterpretations of Abbreviations in Medical Record Documentation

In a reliable medical transcription company, the team of professionally trained medical transcriptionists would have in-depth knowledge of clinical abbreviations and their use. In addition to this, they would constantly update their awareness and have reference materials and lists of abbreviations handy to help deliver accurate and timely documentation.

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Consultation Reports in Medical Transcription

30-March-2015 MTS TEAM Medical Transcription

Consultation Reports in Medical Transcription A consultation (CONS) report is among the ‘Big Four’ reports in medical transcription work and is typically requested by a primary care physician from a specialist for an expert opinion regarding a particular diagnosis or illness. In addition to primary care physicians, emergency room (ER) physicians call in relevant specialists for a psychiatric evaluation, a cardiology assessment or advice on managing kidney failure after making an initial assessment in hospital settings. The consultation report comprises of the physician’s evaluation of a patient, the consultant’s evaluation of that patient and the health condition and the consultant’s recommendations.

Most physicians dictate consultation reports and get them transcribed by in-house medical transcriptionists or a medical transcription service provider. The transcriptionist will listen to the recordings and transcribe the reports in proper format along with the appropriate headings. Depending on the complexity of the case, the length of consultation reports will vary from a few paragraphs to several pages. However, a consultation report typically contains some or all of the sections given below (we discuss how a cardiology consultation report is transcribed):

Patient’s and Physicians’ Details, Consultation Date – This section has patient demographic information, the consultation date, and the names of the referring and consulting physiciansPATIENT NAME: Ashley Woods
PATIENT MR#: 407563
DATE OF CONSULTATION: 21/05/2014
REFERRING PHYSICIAN: William Baum, MD
CONSULTING PHYSICIAN: David Mayer, MD
Reason for Consultation – The reason for a patient visit is explained in a few words or sentences. Headings typically used are ‘Reason for Consultation’ and ‘Chief Complaint’REASON FOR CONSULTATION: Surgical evaluation for coronary artery disease
Details of Present Problem – This is essentially a review of the patient’s initial history and physical examination report along with the additional information obtained from the patient by the consultant. A detailed description of patient’s current problem is described under the heading ‘HISTORY OF PRESENT ILLNESS’, ‘HISTORY OF PRESENTING ILLNESS’, ‘HISTORY’ or another variation
Past History – The patient’s medical history is included in this section such as previous medical conditions and surgeries, allergies, medications, social and family history. Previous medical conditions and surgeries are briefly described and numberedPAST MEDICAL HISTORY:1. Coronary artery disease with previous PTCA and stenting procedures.
2. Dyslipidemia.
3. Hypertension.
Review of Symptoms – This section describes the symptoms currently reported by the patient such as headaches, nausea, vomiting, constipation and more
Physical Examination – Physical examination findings are described here which typically focus on the body parts or system being assessed
Laboratory and Diagnostic Findings – The important laboratory results and diagnostic studies are described here in block or letter version
Impressions and Recommendations – Impressions involve the consultant’s conclusion about the patient’s diagnoses and the recommended treatment are described under ‘Recommendations’ or ‘Plan’ heading

Experienced service providers transcribe consultation reports based on the format in which they are dictated by the physicians. An in-hospital consultation report is likely to have the formal block format, while the letter format is used for consultation reports during an outpatient office visit.

Need for Accurate Documentation While Prescribing Drugs for Insomnia

26-March-2015 Julie Clements Allergy & Sleep Medicine Transcription

Proper diagnosis of insomnia is important to prescribe appropriate drugs. Insomnia or sleeplessness may be due to a mental disorder, or a medical condition; it may be psycho-physiologic insomnia, idiopathic insomnia and so on. Unless the nature of the actual condition is known properly, it is not possible to determine which medications will work on the patients. Documentation of the patients’ health condition plays an important role in the proper diagnosis and treatment of insomnia.

The following details are very critical for doctors to diagnose insomnia:

Medical History – With this, doctors can understand whether the patients have any new or ongoing health issues, painful injuries, show symptoms or have a history of depression, anxiety, or psychosis, are going through highly stressful life events, use caffeine, tobacco, and alcohol or have long-distance travel history. They can also find out whether the patients’ family members have sleeping disorders with medical history. This information will help the physician to determine what’s really causing insomnia.
Sleeping History – Doctors will get details regarding the sleeping habits of patients with sleeping history such as how often they have trouble in sleeping, the time at which they sleep and get up on workdays and off, how long it takes them to fall asleep, whether they snore, how refreshed they feel after sleep and so on. Sleep history also include the details of what they drink or eat before sleeping, at what noise level they sleep, whether any distractions are there, whether they worry about falling asleep, staying asleep, or getting enough sleep, and what routine they follow before going to bed. With all these details, physicians can understand what’s worsening the patient’s sleeping disorder.
Results of Physical Exam and Sleep Study – Physicians often recommend physical exam or sleep study to rule out other medical conditions that cause insomnia and confirm that the ongoing condition is a sleeping disorder. So, the results of these tests in very critical for diagnosing insomnia.

Documenting all these details is critical for complete and accurate diagnosis. If all these details are not documented well, the consulting physicians will not get enough information to diagnose insomnia or they will get the wrong information about the patient’s condition. This will result in wrong diagnosis, which is very dangerous to the patients. There are several side-effects associated with sleeping pills. For example, benzodiazepines are widely used in the treatment of insomnia. However, its long-term use is linked to increased risk of abuse, misuse, and adverse events. Though dual orexin receptor antagonists (a drug type) are found to have limited side-effects and FDA approved Belsomra, an orexin receptor antagonist for the first time to treat insomnia, doctors can’t determine the dose of medication administered to avoid the severity of side-effects unless the medical history, sleep history and test results shows the adversity of sleeping order.

Documentation is important for doctors to receive correct reimbursement for prescribing insomnia drugs. With proper records, they can assign accurate reimbursement codes. Physicians have to submit prior authorization requests to receive reimbursement for certain drugs depending upon the age of the patient. Accurate documentation is vital to handle claim denials and the appeal process.

Electronic Health Records (EHRs) offer fast access to patient histories with pre-established sleep medicine encounter templates and point and click documentation of the visit. With a combined approach involving EHR and medical transcription, you can enhance the documentation quality further. It is because the possibility for making errors is quite high while copy pasting content more frequently to save time. Limited narrative documentation with templates is another disadvantage. Transcribing the physician’s dictations during a visit and populating those details into relevant fields within the EHR system through Discrete Reportable Transcription (DRT) technology ensures complete and accurate data within efficient electronic documentation system.

Knowledge of Common ER Slang Terms Helps Improve Emergency Room Transcription

23-March-2015 Rajeev Rajagopal Emergency Room Transcription

A medical transcription professional will have to handle diverse medical specialties and scenarios and one crucial area is emergency room transcription. ER documentation is quite challenging compared to types of medical transcription. In ER, the patient condition fluctuates based on variable factors and it is crucial to provide proper and timely care as well as ensure accuracy in medical records. ER transcription demands knowledge of medical terminology related to diverse areas including critical care medicine, plastic surgery, anesthesia, cardiology, O&G, ENT, orthopedic surgery, and much more. Good knowledge of common ER slang terms can be a great help in this scenario for those responsible for documenting care. Proper understanding of medical slang and abbreviations helps to a great extent. Here are some of the most important ER slang terms which a medical transcriptionist should be familiar with:

Ambo – transporting ambulance
Appy – appendectomy
Bagging – artificial respiration performed with a respirator bag, such as an ambu bag
champagne tap- clear tap; no blood
epis – epithelial cells
gorked- obtunded or not alert
four H’s- hypoxemia, hypoglycemia, hypovolemia, and high bladder
lap coly- laparoscopic cholecystectomy
nitro paste- Nitrol, nitroglycerin paste
sed rate- sedimentation rate
triple A- abdominal aortic aneurysm, AAA
serum/urine ozm(s)- serum/urine osmolality/osmolalities (lab)
traked- endotracheally intubated
Ambu- ambu bag, manual resuscitative device
tweak score- scale for assessing alcoholism dependence
vitamin H – ER short form for Haldol

In a professional medical transcription company focused on meeting the accuracy and turnaround time demands of ER, the medical transcriptionists would be well-trained in word differentiation, abbreviations, plurals, foreign terms and slang and jargon used by physicians and other health care personnel. Opting for outsourced ER transcription service is undoubtedly the ideal option for hospitals, healthcare centers, medical emergency centers, and trauma care centers when it comes to ensuring comprehensive emergency room reports.

Why Accurate Documentation is Critical for Diagnosing Parkinson’s Disease

19-March-2015 MTS TEAM Medical Transcription

Parkinson's Disease Though PET and DAT scans may aid the diagnosis of Parkinson’s disease or PD, it cannot differentiate PD and Parkinsonian subtypes. Clinical findings are still used to diagnose PD. However, a study published in the June issue of the Neurology Journal (the official Journal of the American Academy of Neurology) says the four main motor symptoms of PD including shaking or tremor, slowness of movement (bradykinesia), stiffness or rigidity of the arms, legs or trunk, and trouble with balance and possible falls (postural instability) are not unique to the disease but can be found in other neurodegenerative disorders. This implies the need to understand the patient’s health condition better and the importance of complete and accurate neurology documentation.

In order to diagnose PD accurately, the following information is essential according to the National Parkinson Foundation.

A detailed medical history and details of physical examination
A detailed history of current and past medications so that the neurologist can ensure the patient is not taking any medications that will cause symptoms similar to PD
Results of detailed neurological examination
United Parkinson’s Disease Rating Scale (UPDRS) recorded during the exam, which is a universal scale of PD symptoms and created to assess and document the exam of the patient comprehensively and compare it with the patient’s future follow-up visits or to communicate the progress of PD symptoms with other neurologists
Response to medications

From this, it is quite evident that comprehensive and standardized clinical documentation is inevitable for correct diagnosis. Such kind of documentation can help neurologists to understand not only motor symptoms, but also non-motor symptoms of PD including cognitive impairment, sleep disturbances, depression and so on. The study author says if you follow the patients and study their responses to medications longer, the probability of making an accurate diagnosis is higher. This means timely clinical documentation comprised of medication response and details of follow up visits can facilitate correct diagnosis.

With built-in symptom based templates for gait disorders, sensory loss etc., and condition-based templates for PD, electronic medical records (EMRs) are quite effective at providing standardized clinical documentation. However, providers must ensure that they avoid errors such as missed data, incorrect data or incomplete data. Such errors will be propagated to other records quickly and the end result may be disastrous. Busy physicians can continue to make use of medical transcription services if they so prefer because reputable transcription companies offer value-added services in this regard. They allow providers to upload their audio files to the medical transcription company’s online platform, where their transcriptionists transcribe the information. After quality review is complete, the transcribed files can be imported into the provider’s EMR system.

EMRs will become more sophisticated with the development of DRT or discrete reportable transcription. With this, providers can continue the method of dictation and transcription instead of using EMR templates. DRT will directly interface the dictated patient information into the appropriate EMR section. Once DRT technology is in place, the returned transcription can be integrated into the EMR system – each piece of data will be sent to its exact location within the EMR.

Use of HIT in Physician Offices Will Significantly Reduce Future Demand for Physician Services

16-March-2015 Julie Clements Medical Transcription

A Commonwealth Fund-Supported study published in Health Affairs in November 2013 says that the proliferation of health information technology (HIT) across physician offices will substantially reduce the future demand for physician services in the U.S. Health information technology adoption includes EHR, clinical decision support, provider order entry and patient Web portals with secure messaging. A commentary in the Journal of the American Medical Association (JAMA) also pointed out that with mobile health apps and home monitoring, physicians will end up seeing only occasionally for minor acute problems and follow-up visits than at present.

Around 72 percent of office-based physicians had adopted electronic health record (EHR) as of 2009, up from about 10 percent a decade ago. The authors of the Health Affairs study opine that HIT on its own and as part of an overall transformation in healthcare system will cause a considerable decrease in the demand for generalist and specialist physicians in the future.

However, the comprehensive use of HIT by even 30% of office-based physicians will take at least five years, says this study. A higher level of transformation can be expected by 2020. Here are the key findings of this research:

Health information technologies such as interoperable EHRs, clinical decision support, patient web portals and more can raise efficiency to a great extent. The study estimates 4 to 9 percent decrease in the demand for physicians in future if such technologies are completely implemented in 30 percent of physicians’ offices and 8 to 19 percent decrease in demand if implemented in 70 percent.
Many duties from physicians will be delegated to nurse practitioners and physician assistants and from specialists to generalist physicians owing to the efficient HIT support. This kind of practice can cause 6 to 12 percent decrease in the demand for physician care (specialist physicians if delegating care to generalist physicians) in case of 30% penetration of HIT, and 12 to 26 percent decrease in demand if HIT adoption is 70%.
The study says 5% to 10% of real-time office-based care could be provided remotely for patients with health information technologies if they are not able to present in a physician’s office. About 5% to 15% care would encompass communication between patients and health care providers from both separate locations and different points in time. HIT involving remote and asynchronous care could reduce the regional shortages of physicians by 12 percent though there would be 7 percent decrease in demand for physicians in case of 30% penetration of HIT and 15 percent decrease for 70% penetration of HIT.

According to the health care experts, full-service acute care hospitals do not need to depend on a long-term physician-patient rapport since they are well-equipped with facilities for comprehensive healthcare services without needing to maintain a team of specialty physicians. This study says that such hospitals will become much more independent due to the decrease in demand for physicians. However, they to stay competitive they would need to find solutions to resolve the challenges related to the effective adoption of EHR and other HIT technologies:

EHR adoption is itself posing a problem and there is evidence of decrease in provider productivity since its introduction. Physicians are finding it difficult to capture meaningful conversations with EHR drop-down boxes and templates.
When information is copied from one file to another in the EHR system it could result in the entry of irrelevant or wrong information.
Speech recognition software does not guarantee accuracy in clinical documentation. The software does not recognize grammatical mistakes and understand the rules of punctuations. It also does not have the ability to expand acronyms.

Future predictions on the demand and supply of physicians should take all of these factors into account. It will be also necessary to train physicians in using new technologies – they will have to become computer savvy as well. Busy physicians have other viable options too. They can employ medical scribes to enter information into the EHR. They also make use of the services of professional outsourcing companies for medical transcription that offer EHR-integrated documentation solutions.

How Gastroenterology Transcription Services Help Doctors

MTS TEAM Gasteroenterology transcription

Gastroenterology transcription involves transcribing data related to various conditions of the abdomen including liver disorders. The symptoms of liver disorders can be so uncharacteristic that one wouldn’t associate them with anything connected with the liver. Gastroenterologists play an important role is deciphering the symptoms and helping patients realize when things are wrong with this important organ. Realizing early helps take the required steps to prevent the condition from getting worse.

Accurate Recording of Patient Information

Accurate recording of diagnosis reports containing details of the reported symptoms and the doctor’s conclusion is very important in justifying the treatment administered and the resultant payment the doctor receives from the patient’s insurance provider.

Right from the time the patient makes the first visit to the physician or healthcare center, healthcare providers deal with data, from the personal and health details of the patient to the observations of the treatment administered and the patient’s reaction to the treatment. Recording and formatting this data for future use consumes significant time and resources. With efficient medical transcription services doctors would only have to dictate the details and get the information recorded and presented in the format of their choice.

Customized and Real Time Delivery of Data

Efficient gastroenterology transcription services would help delivery of patient information in real time, and to increase efficiency of the doctor or healthcare facility, these services would also integrate with the information systems already existing in the facility in terms of dictation options, format of the files to be returned, document routing, and the interface of the file transfer software. The services would also be customizable. The bottom line of all this is, doctors and other healthcare professionals of the facility have all the data regarding diagnosis reports, treatment reports and patient history whenever they need it, in the format that’s most suitable for them. Patient treatment gets the first priority since the gastroenterologist can focus on it.

EHR Services

The scope of modern medical transcription has increased to the level that the transcription company can enter the patient details discretely into the EHR (electronic health record) as well. That saves even more resources and time for the physician or healthcare practice. This service is called DRT (discrete recordable transcription) and is quite the future of transcription in the healthcare industry.

Liver disorders could also be fatal which is why it is integral that healthcare practices and gastroenterologists streamline their functioning to improve efficiency and reduce costs so that they could be fully focused on the treatment. Efficient transcription outsourcing services could help improve clinical documentation, medical coding and the overall outcome. EHR services could further help bring down costs.

How to Improve Typing Speed – A Much Needed Skill for a Medical Transcriptionist

12-March-2015 Rajeev Rajagopal Medical Transcription

Excellent typing speed is a much-needed skill for a medical transcriptionist, along with a number of other skills such as accuracy, grammar and in-depth knowledge of medical terminology. The aim should be to have reasonably good speed with few typing errors. Specific turnaround time is what matters the most in medical transcription service and good typing speed helps attain this goal. Here are some tips to help medical transcriptionists improve typing speed:

Posture is important. It is important to sit up straight with the feet on the ground and the wrists level with the keyboard
Knowing the keyboard well is crucial so that the specific keys can be tapped easily and quickly. Good knowledge in the shortcut keys can save a considerable amount of time.
Using both your hands and more importantly, gaining a thorough understanding of the placement of the fingers on appropriate keys enhances typing speed, such as the thumb for space bar, certain fingers for shortcuts and others for alphabets/numbers, and so on.
Try to avoid looking at the keyboard when typing – keep your eyes on what you are typing. This kind of touch typing is practiced by experts in the field.
Practice typing along with what is being played instead of replaying the dictation the second time, which would result in loss of time.
Practice typing accurately the first time.
Make use of online typing software to practice and improve speed.

In good medical transcription companies, transcriptionists undergo intensive training to achieve the maximum typing speed without compromising on accuracy and quality. An average typing speed of 70 WPM with 98% accuracy is recommended for a medical transcriptionist. It is also up to the quality assurance team to ensure accuracy levels of at least 99% in the final documentation.

Why EMR is Rated Beneficial for Physicians and Patients

09-March-2015 MTS TEAM Medical Transcription

EMR Electronic medical records (EMR) have many benefits and if implemented efficiently can improve patient care and co-ordination among multiple caregivers. An electronic medical record is a digital version of a paper-based medical record and can be more easily managed. This well-structured mode of gathering, preserving, retrieving, and sharing of patient records is expected to enhance patient care and physician efficiency, thus improving practice productivity. The deadline for implementing EMR in the US is January 2015.

As doctors can easily retrieve patient data, patients can benefit from quick diagnosis and timely treatment. The system helps physicians take note of patients who are lagging in screenings and preventive visits, so that timely reminders can be sent. Even details regarding vaccinations and blood pressure readings of specific patients could be checked out promptly.

Let us have a look at the advantages EMR system can offer physicians.

Speedy transfer of patient information from one department to another will help in making prompt diagnostic and treatment decisions.
The space required for paper document storage could be saved and utilized productively for some other purpose.
Actions such as chart-pulls that are time-consuming and labor-intensive can be avoided.
Practitioners need not worry about malpractice risks and can avoid possible mistakes with the availability of structured and accurate documentation.
With organized workflow, considerable time and costs can be saved that can be invested wisely for core administrative and clinical operations.
Any accidental alterations that are likely to happen with handwritten or manually transferred files can be avoided. Electronic data sharing enhances result management and patient care.
The healthcare unit can utilize the advanced features offered with e-Prescribing and clinical documentation for better efficiency.
With advanced tracking systems, the fear of lost or misplaced patient files can be minimized to a great extent.
The software ensures improved communication, sharing and usage of patient healthcare information.
The relevant patient data can be tracked over time thus improving the quality of care.

However, there are some practical difficulties when it comes to fully depending on EMR. EMR with medical transcription integration would be an ideal choice. For that, the services of a reliable medical transcription company can be hired. Providers can dictate their reports and upload the audio files to the transcription company’s online platform. Their transcriptionists would transcribe the information, and the transcripts would then be put through a quality assurance process. Error-free transcripts are then uploaded to the online platform and then imported into the practice’s EMR system. Discrete reportable transcription (DRT) is projected as the next advancement in EMR development. With this, providers can continue to dictate and get the reports transcribed. DRT will directly interface the dictated patient information into the appropriate section of the EMR. This system would allow deep integration of the transcription into the EMR system.

Documenting History of Present Illness (HPI) Report in Ophthalmology Care

07-March-2015 MTS TEAM Ophthalmology Transcription

Obtaining an accurate history is the critical first step in determining the etiology of a patient coming with eye problems. Most of the time, you will be able to make a diagnosis based on the history alone. However, the value of the history depends on the ability to elicit relevant information and that’s why accurate documentation of History of Present Illness (HPI) report is crucial in ophthalmology care. Let’s see how an HPI report is documented.

HPI report is the chronological description of the development of the patient’s present illness from the first sign or symptom or from the previous encounter to the present. The following elements may be included in the report.

Location – This refers to the exact site where the patient is feeling the pain or discomfort (for example, eye or adnexa). You should also indicate whether it is unilateral or bilateral.
Quality – If the patient is experiencing pain, then the nature of the pain should be documented. Specify whether the pain is constant, improved or worsening. If there is problem with vision, indicate whether the patient experiences blurry vision, foggy vision or double vision.
Severity – It represents the degree of pain or loss of sight. Describe the pain or redness on a scale of 1 to 10 here with the score 10 being the worst.
Duration – Indicate how long the issue has been a problem for the patient. You can specify the date of onset here.
Timing – This represents morning/noon, mealtime, rising from prone position or lying down.
Context – Indicate whether the problem is associated with any activity (for example, after medication or while reading or driving).
Modifying Factors – This refers to the efforts the patient has taken to improve the problem. This may include medication/therapy, heat versus cold, artificial tears, opening or shutting of eyelids, and whether there has been no improvement or whether the condition worsened.
Associated Signs and Symptoms – This allows you to indicate any associated signs and symptoms with the problem such as halos, pain, headache, twitching, tearing, discharge, redness, dizziness, blurry vision, floaters or foreign-body sensation.
Status of Chronic or Inactive Conditions – If the patient has any inactive or chronic condition such as glaucoma or cataracts, then the current status of that condition should be specified.

Types of HPI Reports

There are two common types of HPI reports such as:

Brief HPI – A brief HPI is defined as the documentation of one to three elements of the present illness.
Extended HPI – An extended HPI is defined as the documentation of four to eight elements of the present illness

EHR for HPI Report and How Transcription Is Important

With the EHR incentive program, ophthalmology practices are increasingly migrating from paper-based charts to electronic records. The pre-loaded templates within EHR help physicians enter and retrieve patient history quickly. The patient’s records can be delivered to specialists and other members of the care team, if using a cloud-based system. Ophthalmologists can take quick treatment decisions with this and provide care without any delay. However, transcription continues to be important to overcome the challenges with EHR and ensure quality care.

The major disadvantages with EHR are as follows:

The templates impair the normal flow of open-ended questions and the physician’s focus on the patient. Instead of concentrating on the patient’s reactions and behavior, physicians have to look at their computer screen while the patient is discussing his/her problems. Crucial information may be missed out of the report due to this.
The pre-loaded templates limit the narrative description so that the patient’s HPI report may not be comprehensive.
As the number of patients increases, physicians may often miss entering some details while hurrying up to balance their time between documentation and patient care

This is why transcription still important to generate accurate history reports. However, efficient electronic record systems are important as well. The best option is a combined approach of EHR and transcription. In this approach, physician dictation is transcribed with the help of experienced medical transcriptionists and the transcribed data is populated into appropriate fields with EHR. This will ensure the completeness of reports, allow physicians to spend more time with their patients and improve the quality of care provided. A professional transcription company would offer three level quality assurance with proofreaders and editors to improve the accuracy of history reports.