Medical Transcription Record Keeping

A medical transcriptionist has to keep track of the number of lines, words, pages, etc., that they type on a daily basis. Sometimes they are required to keep records of patient names, tape numbers, etc. 

You need good record keeping in case of missing dictations in a patient's file. Hospitals and clinics are very busy all of the time and sometimes you will have to send them a copy of a dictation that you did in the past. I have to do this fairly often. Sometimes it will be for a medical transcription I did weeks or months ago. It is your job as an MT to keep track of all transcriptions that you do. 

You can use a data base on your computer to store this information. A spiral notebook can be used for keeping track of your line and word count if you are not provided with forms to use by the healthcare provider.

Keeping good records is a part of the job, so set up the system you will be using as you are setting up your office. 

Medical transcription services

Medical transcription outsourcing: Helps save on efforts

Medical transcription has always played an important role in the process leading to quality healthcare, by creating medical records of patients  that are  accurate, timely and secure. To meet these criteria of being accurate, timely and secure, the transcription process needs to have inputs like the right team, the right process and the right technology. 

Though medical transcription plays an important role in the healthcare process, it is not part of the core business of the healthcare facility. Focusing on medical transcription would dilute the focus of the healthcare facility not only in terms of resources, but also in terms of time and efforts of the administrative, management, information technology and support staff. Outsourcing medical transcription to a professional service provider not only ensures speedy, accurate, secure and cost effective creation of patient records, but also saving on efforts.

How does outsourcing medical transcription help healthcare facilities save on efforts?

·                     Saving on effort for sourcing and training medical transcriptionists: The quality of medical transcription is largely dependent on the caliber of the transcriptionists. Recruiting and training the right talent is a continuous process. Outsourcing saves on the effort having to source and train the right team.

·                     Saving on effort of sourcing and maintaining equipment for medical transcription: Medical transcription requires equipment like computers, earphones, foot pedals, furniture etc. Outsourcing medical transcription saves on the effort of sourcing and maintaining the equipment required the transcription process.

·                     Saving on effort of collecting and uploading audio files for transcription:Outsourced medical transcription service providers would have a process by which the dictation of healthcare professionals would automatically be transmitted to the service provider for the transcription process. This not only saves on the efforts of the support staff, it also ensures that speedy turnaround time.

·                     Saving on efforts for creating a system for medical transcription: Medical transcription needs to follow a certain process to ensure automatic creation of medical records, which would require a system for uploading dictation and downloading transcripts. Outsourcing ensures saving on the efforts of creating systems required for medical transcription

·                     Saving on efforts for following up for medical transcription work status: The outsourced medical transcription service provider would automatically provide job summaries of the audio files uploaded, the work in progress and finished transcripts, saving the efforts of the support staff.

·                     Saving on effort for ensuring accuracy and turnaround time: The efforts needed to ensure the highest level of accuracy and tight turnaround times would be saved by outsourcing medical transcription.

·                     Saving on efforts for document delivery: Different healthcare professionals require different modes of document delivery depending on the situation. Outsourcing medical transcription ensures that transcripts are delivered as per the modes specified by the healthcare professionals.

·                     Saving on efforts for ensuring HIPAA/ HITECH compliance during the medical transcription process: Medical transcription is a process where confidential data is transmitted back and forth, outsourcing would ensure that the service provider would have secure technology, secure processes, secure infrastructure and enlightened team to ensure HIPAA / HITECH compliance.

·                     Saving on efforts for managing the medical transcription process: The entire medical transcription process requires constant efforts to ensure quality standards are met with, to which end it is important to manage all the aspects that contribute to the process. Outsourcing ensures that the effort of managing entire transcription process professionally is the onus of the service provider.

·                     Saving on efforts for continuously upgrading systems: The software and tools required for medical transcription services need constant upgrades to be secure and efficient. When the transcription process is outsourced the service provider upgrades the system on a regular basis keeping it up to date.

TASP and Medical Transcription

TASP stands for Transcription Application Service Providers.

Medical Transcription is not a cottage industry anymore as it used to be a few years ago. Digitization in this sector has changed the scenario and work environment. Earlier, I remember the days when Medical Transcriptionists (MT) had to take trips every week to their client offices for audio tape pickups and delivery of their work. Today there are many web based application service provider platforms that caters to different types of large, medium, small and also individual home based MTSOs (Medical Transcription Service Organizations).

The TASP type of files routing system is very efficient. It manages the entire process or life cycle of the document, right from the time of dictation at the hospital / physician's location to sending it for transcription/editing to the MT and back to the medical professional. This type of system does save a lot of time and money when compared to the earlier transcription methods. There are dial in systems that take dictations. Playback happens when the residing codec (analog to digital converter) creates a digital sound file that the medical transcriptionist can playback and transcribe.

What are the benefits of going for such a digital technology for these medical transcription companies? Well it includes,

• Encrypted document
• No capital investment
• Lower telephone costs
• Better work distribution
• Fully functional work pool module
• Prompt feedback
• Higher accuracy
• Prompt feedback
• Shorter turnaround time
• High security of documents
• Hassle-free document delivery

Medical transcription outsourcing: Provides multiple benefits

In a constantly changing business scenario it is important for all business enterprises to constantly upgrade the services provided by them. To this end it is important to ensure that the quality of inputs used by the business process not only meets the highest quality standards to provide quality services, but also are also optimally priced to ensure commercial viability. In case of vital services like healthcare the quality of inputs are of absolute importance considering the nature of the services and the cost of inputs also play a vital role considering the pressures on the healthcare sector.

Taking this challenging scenario into consideration, it becomes important for healthcare facilities to carefully consider the cost and quality of inputs that aid in the healthcare process. One such important input is information from patient medical records; this plays an important role in several aspects of the successful running of healthcare facility including the healthcare, the commercial and operational aspects. 

Healthcare facilities have several options available to them for the creation of patient medical records including having an in- house medical transcription department, using independent contractors, documentation by healthcare professionals at the point of care using point and click templates, front end speech recognition software, back end speech recognition software and outsourcing the medical transcription process to a professional medical transcription service provider.

Weighing the pros and cons of all the documentation methods it can be said that outsourcing medical transcription to a professional medical transcription service provider can provide multiple benefits.

What are the benefits of outsourcing medical transcription?Outsourcing medical transcription to a professional medical transcription company provides multiple benefits including:

Quality: One of the aspects that is most benefited by the experience and expertise of the medical transcription service provider is the quality of services. Quality in medical transcription can be defined by the accuracy levels and the ability to meet turnaround time commitments. Using a combination of the right team, the right process and the right technology, outsourced medical transcription services ensure maximum accuracy and meet the turnaround time specified.

Flexibility: Another notable advantage of outsourcing medical transcription is the flexibility of services. This would positively impact several aspects including:

1.                              Quantity: It is impossible for healthcare facilities to predict their transcription requirements, as this would depend on the patient inflow, which is impossible to predict. Outsourcing medical transcription ensures that healthcare facilities are assured of quality services regardless of the volumes without having to employ extra staff for transcription or deal with idle capacity

2.                              Modes of dictation: Outsourced medical transcription service providers also allow healthcare professionals to use dictation devices they are comfortable with. This ensures savings on investment for new dictation devices and optimization of time for healthcare professionals

3.                              Modes of delivery: Outsourced medical transcription service providers also provide flexibility in the modes of document delivery. This ensures that healthcare professionals can receive transcripts through the modes specified by them include delivery to multiple users, remote faxing/printing etc.

4.                              Holiday and weekend transcription: Outsourcing medical transcription also ensures seamless transcription services for weekend and holiday needs.

Convenience: Outsourced medical transcription service providers have not only used technology to provide multiple benefits but also have made it very convenient for healthcare professionals and other support staff to use. Whether it is uploading audio files or downloading transcripts or access to archives or job summaries depicting status of work, outsourced medical transcription service providers have made it very convenient to access and use.

Economical: Outsourcing medical transcription has a definite and positive impact on cost. Outsourced medical transcription services help save as much 40% and above on costs, limit the cost to cost per line and convert the fixed cost of medical transcription to variable costs by charging on the volume of transcription rather than charging a fixed amount.

Secure: Another important aspect of medical transcription is the need for maintaining confidentiality and security of the patient information. Medical transcription service providers are aware of the legal and moral obligations of maintaining HIPAA and HITECH compliance and ensure this by securing technology, processes, people and infrastructure.

It can be concluded that outsourcing medical transcription to a professional medical transcription service provider can have multiple benefits.

Medical transcription outsourcing: Providing information rich services

Healthcare is a service that is vital in today’s world both in terms of providing services that save lives and services that help improve quality of life. Information has a huge to role to play in the delivery of quality healthcare. The process of healthcare starts with information collection and is enhanced by having this information made available to them in an easy to use format at the right time. Medical transcription has a large role to play in transforming the data collected during the patient encounter into information that is legible, clear, accurate and in a convenient format.

The process of medical transcription converts the dictation of the patient – healthcare professional encounter into textual format using a combination of skilled medical transcriptionists, the right process and the right technology. This ensures that the patient medical records are accurate, available on a timely basis, transmitted through secure channels and at a reasonable price. Considering the inputs required for managing a complex and variable process like medical transcription, outsourcing medical transcription to a capable and reliable medical transcription company has been found to be one of the best options.  Creating patient medical records using medical transcription services results in information rich transcripts

Some of features of information rich medical transcription services are:

·                     Using dictation as a means of capturing information: Using dictation as a means of capturing data at the point of care is one of the most preferred methods by healthcare professionals as opposed to entering data themselves or editing back speech recognition software.  Outsourced transcription services allow healthcare professionals to use dictation devices of their choice. This enables them to concentrate on the patients during the visit and record the details later. This has the double benefit of increasing productivity and quality reports

·                     Capturing the entire patient story: Using the services of a professional medical transcription service provider ensures that healthcare professionals have the freedom to capture the entire patient story including the narrative portion. Capturing the narrative portion helps in providing better care and also offers protection against litigation by providing an information rich narrative of the care process.

·                     Providing access to this information for future use: The process of care could continue over time and healthcare professionals may need to access information after a period of time. Reports created by medical transcription companies would have information rich content ensuring that healthcare professionals and support staff do not have to entirely on their memory or patient themselves to recall the details of patient medical history. Moreover outsourced medical transcription service providers also archive these records on a periodical basis and these are easy to access using various search criteria. 

Apart from the above advantages of outsourcing medical transcription, transcription services also provide services with advantages like:

·                     Timely transcription ensuring specified turnaround time

·                     Easy to use technology for transcription, which lower the burden of healthcare professionals and support staff

·                     Editing and proofreading services for transcripts created by speech recognition software

·                     Adoption of EMR/. EHR using HL7 interface

Medical transcription: Tips for successful outsourcing

Healthcare services have been recognized as not only essential for improving the quality of life they have also been recognized as an essential indicator of the economic growth of the nation. The healthcare sector has always had to face numerous challenges towards the path to providing quality healthcare while still maintaining a healthy bottom line. One of the main ingredients that contribute to the delivery of quality healthcare and maintaining a healthy bottom line among numerous other factors is the information from patient medical records.]

There are numerous methods of creating patient medical records including direct entry into EMR/EHR system, speech recognition software, having an in-house medical transcription team, using independent contractors and outsourcing medical transcription to a professionally managed medical transcription service provider. Outsourcing medical transcription to a professional service provider has been found to be one of the most efficient and cost effective methods of patient medical record creation.

However healthcare facilities and healthcare professionals have numerous concerns about outsourcing a vital function like medical transcription. While it is important to assess the medical transcription service provider based on criteria like accuracy, turnaround time, cost security and the software & technology used for medical transcription, it is also important to focus on a service provider who can be more like a long term partner rather than vendor.

Given below are a few tips to ensure successful transition to outsourced services:

Communication: It is imperative that the healthcare facility and the medical transcription service provider have effective communication channels. Having easy access to the service provider can help solve any queries, provide timely support, improve services etc

Flexibility: Medicine is a huge field and the needs of this field vary vastly based on numerous factors. The medical transcription needs of a healthcare facility could vary based on various factors like the specialty being transcribed, the patient influx, the need/ preference of the healthcare professional and numerous other factors. One of the basic foundations for the successful outsourcing of medical transcription is to source a medical transcription service provider who can provide flexible services based on the need of the hour, without compromising quality.

Develop effective two-way feedback system: The quality of the patient medical record depends both on the originator of the document (the healthcare professional) as well as the medical transcriptionist. It is important for healthcare facilities and healthcare professionals to give and accept feedback from medical transcription service providers regarding measures to improve quality of dictation

Growing together: The documentation needs of the healthcare sector are dynamic, it becomes imperative to choose a medical transcription service provider who can keep up with the changing needs of the healthcare facility, This could involve keeping up with changes in healthcare, technology and statutory requirements.

There are numerous factors that make the outsourcing process successful, some of the main being clearly defining the objectives of outsourcing medical transcription and communicating the same to the medical transcription service provider. It is also important to have two-way communication with the service provider. Having all these measures in place would bring about successful transition to outsourced medical transcription services.

Medical Transcription Outsourcing - A Profitable Option

Medical transcription companies have become very sought after these days as the healthcare units are struggling to maintain the increasing number of medical reports on a regular basis. Besides providing superior quality service, the transcription providers have kept the rates very competitive. This makes medical transcription outsourcing a profitable optionfor most healthcare providers.

Low Cost Medical Transcription Service Providers

The medical transcription companies offer very competitive rates. They save the medical professionals other expenditures in terms of recruitment of extra staff for maintaining the daily medical records, investment on office resources and generally increasing the size of the office. They also help the medical professionals in preventing backlog and loss of medical reports due to piling up of work. These providers also give flexible dictation options to the medical professionals through digital machines provided by them or through toll free phone numbers. These companies have advanced technology and software which ensures superior quality of work.

Other Benefits of Outsourcing Medical Transcription Work

Apart from being a cost saving option, there are several other benefits that come with outsourcing the transcription work to reliable providers. These are:

* Quick turnaround time which can be customized according to need
* Multi-level checks for greater accuracy of all documents
* Documents are 99% accurate
* File Transfer Protocol for delivering files in a secure manner
* Experts work for you and ensure high quality of work
* 24x7 customer support service

With all these benefits provided by the medical transcription companies, it's small wonder that almost all healthcare units and medical professionals are outsourcing their transcription work. Most associated people look at medical transcription outsourcing as a profitable option -- a boon that has made life much easier.