The Importance Of Accurate Medical Transcription

Doctors, surgeons and nurses have some of the most important and stressful jobs in the world. Not only do they have their patients’ lives in their hands, but they have to constantly keep up with whatever the latest best practice is as medical knowledge evolves. So a part of their career involves ongoing education.

What is more is that it is vital for all of them to keep written notes so that everyone attending to a patient is on the same page. When a patient goes into a hospital they may be seen by a consultant, operated on by a team of surgeons and nurses, and attended to by nurses as they recover, and may very likely be seen by other doctors who come around to check on their condition. So it is critical that everyone involved in their care knows exactly what is going on.

For example, a doctor may need to prescribe urgent medication for a patient, but she may have an allergy to something that is contained in a particular medicine. If the doctor doesn’t know that she has an allergy, there could be some disastrous consequences. Even when you have a GP, you may have a medical problem when your doctor is on holiday, so you will be seen by another doctor in the practice.

Then there is the question of doctors in private practice. When they have to bill an insurance company,that company will want the correct medical records and if they don’t get them the doctor won’t get paid.

Accurate medical transcription is not just something that is good to have, it is critical. Whether it is a doctor’s notes, speeches from a medical conference, interview recordings, and more, it is vital that the transcript is nothing short of correct. The medical sector uses words that are entirely its’ own, and way beyond the understanding of the man in the street, so the transcriptionist has to be someone who has some sort of medical training. Furthermore, non-English accents can make transcription even more difficult.

Then there is the question of protection of patient data. In the US they have the Health Insurance Portability and Accountability Act (HIPAA) which came into law on August 21st 1996. This revolutionised medical record keeping and compliance throughout the country, but it necessitated quite an overhaul of record-keeping departments and the standardisation of communications. These records ensure that the right care is administered to each patient, and they also have another purpose which is to serve as a basis for legal arguments if a lawsuit is launched against a medical provider.

In the UK, the NHS has its’ own security policies for England, Scotland, and Wales, and while they are not actually law, they are intended to safeguard patient data and ensure that all departments operate according to the Data Protection Act. This is important because the enforcement agency of the Data Protection Act, which is the Information Commissioner’s Office (ICO), was recently granted greater power by the UK government to audit NHS organisations’ data security.

There is a policy in the UK that all new employees in the healthcare industry should receive security training when coming on board. However, research has shown that 48% of new employees did not receive any security training. Furthermore, when taking on a new employee, it is recommended, although not required, that background checks be carried out. Only 49% of new employees in the NHS have background checks undertaken.

Another basic procedure with new employees is to present them with a security policy, but when interviewed, only 31% of new employees agreed they had been shown one. They were then required to sign it in order to formally agree with it. In England and Scotland, formal agreement to a security policy is a requirement in the NHS, but over two thirds of new employees never saw one!

When using an external medical transcription service, it is vital that they are prepared to sign a Non-Disclosure Agreement in order to protect patient security. The company should also only use first class English speakers who have medical training, or have at least worked in the industry, as their transcribers.

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