The importance of documenting the patient encounter is manifold as it helps in many aspects that contribute to the smooth running of healthcare facilities, besides being a statutory necessity. As healthcare services are critical it is important that the process of documenting the patient- healthcare professional encounter be subject to certain norms. The patient – healthcare professional encounter can be documented by various means, one of the most preferred being medical transcription; a process which converts dictation to text.
As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.
Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.
Act: Continuous quality improvement
As quality is a key word in the medical transcription process, the process of improving quality should be proactive rather than reactive. That is the quality improvement program should aim at preventing errors from occurring rather than correct errors after they occur. To this end the key steps in a quality improvement program should be:
· Review
· Revise
· Communicate
· Monitor
The quality improvement program for medical transcription services should focus on all aspects of medical transcription including:
Dictation devices: The quality of audio is a major contributor to the quality of medical transcription. It is important to address this issue by studying in detail all types of dictation devices to determine which one produces optimum output. It is also important to have a clear idea of the working of the device so as to avoid audio problems like clipped words, garbled words etc
Author education: As the healthcare professional is the originator of the transcript by providing a narration of the patient encounter, it is important to educate the author on dictation best practices. These could include:
1. Choosing the right dictation device
2. Knowing the equipment
3. Importance of choosing a noise free environment for dictation
4. Practice of specifying type of report etc at the beginning of dictation
5. Using the right pace of dictation
It is also important to establish a forum for feedback that flows both ways between the healthcare professional and medical transcriptionists
Medical transcriptionists: The responsibility of transcribing the dictation into transcripts rests for the most part on the medical transcriptionist. It is important to provide medical transcriptionists with the means to produce quality medical transcription. These could include:
1. Provide training
2. Provide resources
3. Provide feedback
4. Use feedback as learning opportunities
5. Distribute samples for difficult authors
6. Provide formats/ templates/ macros/ normal
7. Assign mentors for new medical transcriptionists
8. Provide incentives for quality
Account specific: This would address the issues specific to particular accounts making it easy for medical transcriptionists to produce quality. These could include:
1. Easy to use account specification sheets
2. Constantly update the information on account specification sheets
3. Maintain up to date lists of healthcare professionals etc specific to the account
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