Medical transcription best practices
Medical transcription services are extremely important in the medical field today, as the need for accurate and reliable electronic medical records has greatly increased. Medical transcription alone does not automatically guarantee the medical records produced are accurate and reliable however. Therefore, these transcription services need to follow medical transcription industry specific best practices in order to obtain the goal of creating accurate and reliable records. These include standard best practices for general medical transcription, best practices among specific practice types such as radiology medical transcription, best practices to ensure HIPAA transcription compliance, and best practices when outsourcing transcription services.
General medical transcription service best practices need to focus on specific quality measurements and efficiency metrics. Due to the high importance of both quality and efficiency, medical transcription services are only as useful as the level of these two metrics they are able to obtain. Quality is extremely important as it directly impacts the safety of patients, the accuracy of medical records, and the overall costs of healthcare associated with incomplete and poorly documented medical records. The quality of medical transcription is gauged by accuracy, completeness, and consistency. Two of the main ways these quality and efficiency measurements are measured is through review and analysis of accuracy rates and turnaround time.
Accuracy rates are the prime measurement for quality in medical transcription. A best practice for all medical transcription services is to calculate their accuracy rate according to HPI guidelines. These guidelines aim to improve the overall quality of medical transcription by calculating the errors found within transcription and assigning a numerical point value depending on the type of error. There are 8 potential error types that are factored into the accuracy rate. The first error type is a medical word misuse. This is a severe problem that can result in the wrong diagnosis being recorded which can lead to incorrect treatment and billing. The second error type is omissions. Omissions are also a severe problem due to the consequences of potential mistreatment of patients. The third error type is a medical word misspelling. The fourth error type is an English word misspelling or misuse. These two error types are not as significant as the first two error types, but can still lead to unclear and poor quality medical records. The fifth error is related to inappropriate use of blanks that could have been resolved through research. This type of error is due to a focus on speed and production, rather than on thoroughness and quality. The sixth error type is grammar errors. The seventh error type is punctuation errors. The eighth error type is typographical errors. Finally, the last error type is formatting errors. The values assigned to these error types are factored into the total line count of the medical record. The result of that equation is the accuracy rate.
Turnaround time is defined as the “elapsed time from completion of dictation to the delivery of the transcribed document, either in printed medium or electronically to a repository.” Fast turnaround time is a very important best practice of medical transcription for many reasons. Medical records are often used to subsequently bill for the health services performed. Delays in receiving transcribed records can lead to delays in healthcare provider reimbursements. Patient treatment plans and observations heavily rely on medical records. Delays in receiving transcribed records can lead to delays in developing and properly monitoring patient treatment plans. Therefore, delays can have severe consequences in patient health and safety. Finally, complications from delays in receiving medical transcriptions can have legal implications depending on the severity of each individual situation.
The Health Insurance Portability and Accountability Act, also known as HIPAA, has important requirements relating to best practices in medical transcription as well. The HIPAA transcription compliance requirements mostly come from title II that addresses quality and privacy standards. The best practices resulting from this section of HIPAA are conducting proper trainings on privacy and confidentiality of protected health information and allowing patients access to their personal medical records for the purpose of inspection for accuracy and editing of any incorrect, incomplete, or misleading information. Medical transcription services need to ensure they diligently adhere to these rules within HIPAA and all other applicable rules as well.
Best practices relating to transcription within specialized fields of medicine, such as radiology medical transcription, do not differ much from general medical transcription best practices. One of the most important factors for medical transcription services to focus on within specific fields is medical word misuse. Specialized fields such as radiology have field specific medical terminology and lingo that is not standard to all other medical fields. The dictation could mention a specific radiology term that sounds like a more general medical term but could have a drastically different meaning when out of context. An error related to a misused medical word in this case could easily happen if improper assumptions are made by the medical transcription service assuming the dictator meant the more common medical term. A best practice for medical transcription services in this instance is to research and clarify the medical term if unsure of its accuracy.
Finally, best practices relating to outsourcing transcription services are important to consider as well. A best practice for when medical transcription is outsourced is to ensure that all parties are aware that the work is being outsourced. Outsourcing to foreign countries could have potentially greater quality risks due to language barriers and differences in interpretation. Assessing accuracy rates is even more crucial, therefore, when evaluating outsourcing opportunities in medical transcription.
Medical transcription services are an important part of the medical field today. They have the potential to help improve the quality and efficiency of medical records for healthcare providers and their patients. Following best practices within medical transcription directly results in increased patient safety, reduction in health costs from in accurate records, and improvement in the overall accuracy of medical records.