Best way to handling corrections revision of the Patient Record

The rules to modifying the Patient Record should be strong foundation for the enterprise seeking to develop policies and procedures. In order to ensure the admissibility of the medical record as evidence, the enterprise must first establish policies and procedures that address

• Author authentication
• Medical record access control
• Medical record archiving and retention
• Medical record security
• Medical record disaster recovery policies and procedures

By establishing controls over the creation of medical records, enterprises can ensure the nonrepudiation of corrections, revisions, additions, and addenda made in the normal course of business.

Ultimately, by controlling the how, who, where, and when of creating the medical record, the enterprise establishes the methodology for performing valid corrections, revisions, additions, and addenda.

The best practices of a healthcare enterprise can develop an effective and valid policy and procedure for the correction, revision, addition, and addenda of health information contained within the medical record.

The key characteristics of an effective policy and procedure include

• Author authentication and accountability
• Clear indication of correction or amendment date and time
• Policies and procedures that prevent unauthorized alteration of documents
• Clear delineation of parent document
• Clear delineation of corrected or amended document
• Notification of health information recipients when amendments and corrections occur
• Retention of the parent document for historical reference 

Though it is true that no single rule that addresses medical record transcription and amendment exists, enough guidance is available to allow healthcare providers to develop a workable policy and procedure to address the creation of valid medical record corrections and amendments
Medical transcription companies

Outsourcing Medical Transcription Services

Medical Transcription is the process of converting voice transcription into a permanent written record utilizing word processing equipment and software. Medical transcription is necessary process in medical industry as all medical institutions require computerization of medical notes for clean and compact record-keeping, insurance claims processing, quick reference, conferencing and various other reasons.

Today medical transcription services has almost become a popular term among the health professionals and services are available for all medical specialties. A medical transcriptionist's job primarily involves converting significant and confidential data into written text. This text is printed and included in the patients' records, archived and retained as an electronic medical record.

Before some time staff of skilled medical transcriptionists was working in the medical records department of the hospital has accomplished the work of transcribing medical records. But now a days for any hospital; it is very difficult to afford staff of medical transcriptionists so for that outsourcing is the best option available to save their valuable amount of time and money. By outsourcing their medical transcription related requirements to outsourcing firm they can reduce their burden.

While you are choosing your offshore partner to outsource your needs, you have to be very careful as it requires an attention to detail and an ability to recognize and understand technical terminology.

Medical Transcription Industry back in action ????

It was almost a cottage industry in the 90s, only to lose steam in 2000. 

But if you thought the medical transcription (MT) industry in India is history, think again. 
Latest studies reveal that it is raring to take off yet again. And this time, the future is well chalked out. 

When it took off in the 90s, anyone with a little space and enterprise opened an unit in their living room. 

Unfortunately, the boom didn't last and hit rock bottom in 2001. The reason: Too many entrants, lack of entrepreneural skills and knowledge of industry and security issues. Many small players opted out. 

But since 2004, the sector has slowly but steadily worked its way up. Now, it generates revenues worth $195 million. The figure is expected to go upto $647 million by 2010, according to ValueNotes study. 

In fact, the study found that at present, India-based MT vendors employ around 18,000; by 2010, the numbers will go up to 52,000. A Nasscom study released last month too confirms this northward move of the Indian MT industry. It says India has 120 to 150 Medical transcription companies which earn an annual income of $220 to $240 million. 

According to experts the industry will witness further consolidation with large American medical transcription service organizations eyeing smaller Indian offshore vendors 

Experts say there has been a systematic ramp-up and a steady flow of business from the US to India which is our largest market. 

If things go this way, the industry will see good times again.

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.