Tag Archives: Medical Transcription Services

How to Properly Document Medical Decision Making (MDM)

Medical Decision Making (MDM) documentation is as significant as the other two components of documentation (History and Exam) in assigning an evaluation and management (E/M) service level. The end result of MDM is complexity level or severity of presenting complaint. MDM … Continue reading

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The Versatility of Medical Transcription

The medical transcription industry owes much of its success to its versatility. The industry has adapted well to ever-evolving technologies and health care documentation policies. One of the primary reasons for the huge success of this health care domain is … Continue reading

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PDCA Quality Principles for Clinical Documentation

As the healthcare system in the U.S is shifting from paper-based to electronic health records (EHRs), it has become very important to focus on the quality of patients’ records for improved and consistent patient safety outcomes. This has made the … Continue reading

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How the Combined Efforts of MTs and MTSO Can Assure Quality Documentation

Healthcare reform and advancements in health IT have transformed clinical practices and processes. With electronic health records, it has become even more critical to ensure high quality reporting and healthcare documentation to enhance care, assure patient safety and take care … Continue reading

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Why Medical Transcription Is More Challenging than General Transcription

The role of a transcriptionist involves reproducing recorded dictation in accurate digital text format. The recorded content could be interviews, meetings, focus group discussions, single person dictations, voice mails and so on. Transcription generally falls under three broad headings – … Continue reading

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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 … Continue reading

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

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 … Continue reading

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EHR for Reducing Hospital-acquired Infections in Pediatric Care

A complete and accurate reporting of all hospital-acquired infections (HAIs) is critical in pediatric care as HAIs are associated with longer hospital stays, longer ventilation times, increased cost and adverse neuro-developmental outcomes in children. Electronic health records or EHRs are … Continue reading

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EHR Dissatisfies Many Providers Amidst Huge Investments in Such Systems

Electronic health record (EHR) debates can be contentious. While some praise EHR systems for enhancing the medical documentation process, others find the system burdensome. Contradictory findings are found in even studies on EHR’s impact on physician burnout rates and patient … Continue reading

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Treating Infectious Diseases – Accurate Documentation Vital

Medical transcription of doctors’ recorded observations and treatment details is of great significance from the point of view of appropriate diagnosis and treatment. The transcripts have to be accurate, and there is no room at all for error. Continue reading

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