7 Ways in Which a Medical Transcriptionist Ensures Accurate Clinical Documentation

Medical transcription is the critical process of transcribing a physician’s notes into accurate medical records. Medical reports are documents that record patient details and contribute to high quality care. They enhance communication between patients and the various healthcare providers. They reduce many hassles associated with medical claims processing and also serve as legal documents when needed. Hence accurate medical documentation is essential and this can be achieved with the help of skilled and experienced medical transcriptionists.

How a Medical Transcriptionist Ensures Accuracy

Here are seven ways in which an experienced medical transcriptionist would ensure that your medical documentation is accurate and reliable.

Check and recheck the final records

Once the documentation is done, the final records would be thoroughly proofread to detect any errors. Proofreading and rechecking of the documented facts ensures that the patient’s name, medical details and dates are entered correctly. This will also provide the opportunity to correct any inconsistencies in the documents.

Apply their knowledge about medical terminology, anatomy and physiology

Good medical transcriptionists will be well aware of relevant medical terminology, anatomy and physiology, lab and radiology values. They can easily identify any incorrect entries regarding dosages of medications. They would:

Know what drugs work for what medical condition

Have a clear understanding of the body parts and their functions

Know common lab values to identify outliers

Knowledgeable about age- related illnesses, conditions or disorders

Utilize drug book and other tools for reference

A dedicated medical transcriptionist will usually have a drug book for ready reference and to know the dosage details. They would also make good use of the various research resources available and reliable websites to ensure accuracy when the dictations are confusing and ambiguous. Sample dictations (from specific dictators from which protected health information has been scrubbed) may be used to clarify later dictations since physicians often use the same phrases while dictating and use of these samples helps in transcribing dictations accurately.

Make use of their excellent listening skills

A good medical transcriptionist would employ his/her keen listening skills to capture every important word dictated by the physician even when there are disturbing background noises. They would notify the physicians if there are medical discrepancies. Listening simply to the dictated words is not enough, understanding the meaning is also essential since it will limit the need for correcting errors in the medical records. This is what reliable medical transcriptionists ensure.

Work with the physicians

It is important that transcriptionists work closely with the physicians if documentation is to be efficient. If any doubt arises at the time of transcribing, they would clarify the same with the physician and make sure that the medical records are error free and accurate.

Keep abreast with new changes in the medical industry

Medical transcriptionists should be aware about the changing trends in the medical industry. They keep themselves updated regarding new and innovative treatment methods, terminology, new drugs etc. This helps them minimize errors. The innovative method of speech recognition documentation requires special skills and techniques and medical transcriptionists educate themselves on this technique as well.

Stay relaxed

A medical transcriptionist focused on creating accurate medical records knows the importance of staying relaxed and getting sufficient rest. This will ensure that they can deliver medical records with fewer errors.

The Significance of Medical Transcription Services

Irrespective of the method of dictation, accurate medical documentation can be ensured with the support of dedicated medical transcription services. They offer various transcription options and customized services at affordable rates. An experienced medical transcription company ensures:

Timeliness

Confidentiality

Accuracy

Completeness.

Medical Transcription Services is a reliable medical transcription company in the USA, provides transcription to healthcare clients across the United States and worldwide.