The importance of maintaining patient medical records is undeniable in both the operational and commercial aspects of healthcare. Healthcare facilities have various options available to them to document the patient- healthcare professional encounter. The options available for documenting are:
Dictation to transcription The healthcare professional has the option of dictating notes of his/her encounter with the patient. These audio files can be converted into text reports using the following options –
– In-house transcriptionists
– Independent contractors
– Outsourcing to a professional medical transcription service provider
– A combination of any of these above sources
Speech recognition software – This enables the dictation of the healthcare professional into text format using the recognition software instantly. In theory this sounds like the best solution. But this method has many shortcomings, some of which are –
– The software needs to be trained
– The healthcare professional has to change his method of dictation
– The document produced by speech recognition software is only 60%- 80% accurate, Imedical Healthcare Solutions needing extensive editing and quality checking
Direct entry into EMR/EHR – This enables the healthcare professional to capture data at the point of care using point and click templates. Though this method allows for instant documentation, this method has some shortcomings –
– Lack of narrative details
– Decreases the productivity of the healthcare professional
– Focuses the attention of the healthcare professional on the computer instead of the patient
Though there are many options available to healthcare professionals and healthcare facilities for creating patient medical records, all the methods need the support of experienced and skilled medical transcription services to meet all the criteria of healthcare documentation. Outsourcing the entire process to a professional service provider can help healthcare facilities and healthcare professionals meet all the criteria of healthcare documentation.
How can outsourced medical transcription services help meet the criteria for healthcare documentation?
Outsourcing medical transcription to a professional service provider provides healthcare facilities access to all the resources required for healthcare documentation, namely –
Trained and skilled transcriptionists to ensure accuracy and speed
The right processes to ensure quality and security
The right technology to ensure speed, security and ease of use.
What are the principles of healthcare documentation and how do outsourced transcription services help healthcare facilities adhere to these principles?
The principles of healthcare documentation are –
Unique identification of the patient – The medical transcription process ensures that the identity of the patient is captured in the manner narrated by the healthcare professional to ensure unique identification,
Accuracy – It ensures that the information provided by the healthcare professional and the support staff in the audio record is captured with maximum accuracy possible.
Completeness – It ensures that the information provided by the healthcare professional is capture completely to the extent possible.
Timeliness – This process ensures that the patient medical records are created on a timely basis by using the right team, the right process and the right technology.
Interoperability – Interoperability of the data in the patient records can be ensured by the vendor using HL7 interface. HL7 functions as a standard to ensure that critical healthcare information is made available to various sources without the meaning getting lost.
Retrievability – Most outsourced vendors keep the audio records and the transcribed documents on their systems for a period of time as specified by the healthcare facility, after which they are archived. The staff at the healthcare facility can retrieve this data by using various criteria like patient name, MRN no, the provider, the date of treatment or a combination of any of these criteria.
Authentication – Outsourced transcription vendors have the provision of the healthcare professionals being able to electronically sign off on transcribed reports to authenticate them.
Auditability – In case of any missing words or data, these would be highlighted by the transcriptionists so that the healthcare professionals can audit these records and correct the missing/ wrong entries.