It’s not a picnic to work in the medical field. Healthcare providers have a lot on their plates between seeing patients, providing advice, and doing routine checks. Not only that, but they also must keep detailed records of their patients, which is no small feat given the need to record every little detail.
Nurses, doctors, and practitioners use voice recorders to make taking notes easier. However, audio files can’t be included in a patient’s medical record. Thus, they must be converted to text in some way. And that’s where services like medical transcribing come in handy.
The process of turning audio recordings made by doctors and nurses into written documents is known as medical transcription. Following all criteria and requirements, transcribers first take audio recordings and convert them into digital transcripts. It is a great relief for doctors and nurses because, unlike in the past, they no longer must spend time writing up discharge summaries and other paperwork manually.
Medical Transcription Process
Medical transcription follows an 8-step process to ensure accuracy and care, which includes:
1. Setting Up the Secure File Transfer Protocol
So that the client can safely upload the consultation recordings, the doctors are given access credentials, such as an access ID and a private key to upload the voice notes.
2. Medical Transcription
When you hire professional medical transcription services, the transcriptionists will begin typing the dictation into the format requested by the doctor once they have accessed the uploaded files.
3. Multiple Quality Control Measures
To verify preliminary accuracy, the transcribed files undergo quality control, during which Level-1 copy editors review the text and make any necessary corrections. Later, Level-2 QA will make sure there are no mistakes.
4. Editing and Proofreading Transcripts
All transcriptions are reviewed to eliminate typos and other problems before they are released.
5. Document Review Submission
In this step, the doctor receives the final, revised files for approval before uploading them.
6. Collecting Customer Opinions
The client reviews the content once again and either gives their stamp of approval or suggests changes.
7. Use of Electronic Signatures
The doctor’s digital signatures on the files attesting to their accuracy will be transmitted electronically.
8. Uploading Completed Transcripts
The completed file is then saved to the SFTP and delivered to the customer per the SLA.
Types of Medical Transcription Available
- Ophthalmology Transcription
- Discharge Summary Transcription
- Emergency Room Transcription
- Neurology Transcription
- Psychiatry Transcription
- Operative Reports Transcription
- Pathology Transcription
- Radiology Transcription
- ENT Transcription
- Cardiology Transcription
- Deaf Transcription
- Orthopaedics Transcription
- Dermatology Transcription
- Anaesthesiology Transcription
- Gastroenterology Transcription
- And many other healthcare BPO services
Medical Transcription Guidelines
The Association for Healthcare Documentation Integrity (AHDI) is a group that works for individuals and organizations involved in healthcare documentation. By developing a well-trained and supported staff, working with healthcare experts, and partnering with other stakeholders, AHDI aims to ensure that patient health records stay private. For its stakeholders, the AHDI created a basic structure and a set of guidelines. For companies that offer medical transcription as a service, the regulations have gradually grown to be considered standard.
Spacing during typing, numbering/numerical typing, hyphenation, punctuation, drug nomenclature, capitalization rules, measures, symbols to be utilized, classification rules, proofreading, and more are all covered in the medical transcribing guidelines.
When preparing and transcribing a variety of medical reports, it is crucial to adhere to the following basic guidelines.
- It is recommended that the present or a mixed tense be used when describing the current sickness.
- When discussing former medical conditions, only the past tense should be used.
- Allergies should be capitalized.
- Write “No known drug allergies” if tests reveal no sensitivities.
- The present tense must be used in all major physical examination reports.
- Make sure you’re using the right tense of verbs to convey when something happened.
- The title ‘Doctor’ should be typed out in full.
- Spaces should not be used before or after hyphens, slashes, dashes, percent signs, or numbers.
- All medical abbreviations must be fully spelled in the Assessment/Diagnosis/Impression report. But you can shorten the name of a unit of measurement.
- To summarize a patient’s discharge, write in the past tense.
- Medications with a brand name should be capitalized. However, capitalization is not required when referring to generic drugs.
- Use the Latin terminology for drugs.
- All pharmaceutical labels must utilize Arabic numerals, including those for strength, dose, and instructions.
The Conclusion
These best practices are followed by HIPAA-compliant medical transcription companies that provide accurate, quick, and secure EHR transcription solutions. Doctors dictate notes, which are then professionally transcribed and subjected to stringent quality control by editors and proof-readers before being integrated into electronic patient data.
As a result, healthcare providers can save money on transcription costs and reduce turnaround times for transcripts by teaming up with a reputable medical transcription service.
