We have seen doctors and nurses on the busiest and most critical days in the hospital, either as portrayed on TV and movies or in real life. Their time and focus are all directed to caring for the patient and making sure that they are out of harm’s way. However, there are certain things that hinder them from spending more quality time with their patients, and one of them is the amount of paperwork they have to submit per patient. It is important, then, that medical transcription services be utilized by the hospital administration to ensure that the documentation and organization of all health records would not get in the way of the medical team.
What is medical transcription services?
Medical transcription services are an associated health profession that focuses on documenting recorded voice files of doctors for each medical consultation of his patients. Remember the time when doctors write on your patient records each time you visit them? This practice has been substituted by making voice recordings of the complete visit after each patient consultation. The voice file will then be sent to the medical transcription services team employed or outsourced by the clinic or hospital so it could be converted into virtual medical records.
What medical records are transcribed?
If you ask me, any paperwork that needs to be completed for the purpose of documentation can be subjected to medical transcription. But to get into perspective, medical transcriptionists usually transcribe:
- Patient’s medical history and physical examinations
- Surgical notes or post-operative reports
- Diagnostic findings
- Discharge summaries
- Patient-doctor interviews
- Medical researches
- Consultation & Administrative Letters
How does medical transcription services work?
To fully understand how this industry helps our medical team, let us give you an example. A patient walks in the clinic needing the attention of a doctor. The doctor assesses her, gives her a diagnosis, and prescribe certain medications to alleviate her complaints and to treat the source of her disease. The patient then leaves, allowing the doctor to narrate and record a voice file of the whole patient visit. The doctor dictates the information about the patient, including the subjective and objective signs and symptoms, his assessment of the condition, the diagnosis, and the treatment plan that he administered and carried out. He also includes information about follow-ups and certain tests that the patient would need to complete to fully evaluate the patient condition. He then saves the file and attends to another patient in need.
The recorded file will then be sent to the in-house medical transcription department or an outsourced medical transcription services that process the recordings into written reports stored in electronic software for safe-keeping.
What is it like to be a medical transcriptionist?
Medical transcriptionists are different from other general record takers in the sense that their knowledge and familiarity about medical words and practices should be sufficient to make the documentation reliable and accurate. It is an advantage if the medical transcription services offer several training programs and seminars for their employees to remain updated with the latest trends and technologies in the medical field.
Hospitals and other tertiary clinics submit templates of each medical document, so it is easier for the transcriptionist to record the dictated information. Doctors also have their own style in dictating their patient records, so they can also submit their individual document formats to make their records uniform and organized.
Concerns about medical transcription services
When it comes to medical documentation, the hospital administration may be a bit wary about how effective medical transcription services may be. Here are just some of the issues related to the nature of medical transcription and how they manage to answer each one.
General transcription is better and cheaper
Many healthcare providers think that to save money, it is a good idea to employ general transcriptionists to handle the medical documentation for them. This is undoubtedly a wrong move that could sacrifice the quality and accuracy of the whole process itself.
Many businesses are able to hire general transcriptionists to transcribe their audio files as well. This is not an option for healthcare providers. With specialized, esoteric medical industry language and more complicated formatting, it is essential to work with specialized medical transcriptionists who understand and are familiar with the jargon and other technical words and names in the medical industry.
Outsourcing medical transcription defeats the US market for the profession
Because of the increasing demand to document medical records and free up the time of the medical team, there now many countries that also have ongoing outsourcing services for medical transcription. Why do they have to outsource this field? Cheap labor. Yes, there are countries that offer their medical transcription services at a lower price compared to in-house medical transcription options. The greater majority of medical transcriptionists (MTs) currently work from home offices rather than in hospitals, and some of them also work off-site. This situation makes the livelihood of national transcription services at risk, especially in the US. If many hospitals would resort to cheaper medical transcription services offered by other countries, the US medical transcription industry in the US falters. Some would then measure up and offer their services as low as what other nations would, but would make their profit smaller making them at the risk of losing their business altogether to the cheaper outsourced providers.
The reports may not be accurate
One of the risks of getting outsourced medical transcription services is the employment of under-qualified transcriptionists just to save money. Some could understand the English language but are not familiar with the expressions, making their documentation faulty. There are also other providers who offer low cost of services but provide substandard output due to inefficiency and lack of experience of their employees. This can then be regulated by employing transcription editors and a speech recognition software that proof-read all written documents and base them on the audio file provided by the employer.
The privacy of patients are at risk
Because the record-keeping and documentation are being performed by a different person other than the doctor itself, there are concerns about patient privacy. With confidential reports going from the country where the patient originated to a country where the laws about privacy and patient confidentiality may not even exist, patients are becoming wary about the process. What assurance can they get that their identity and classified medical information are protected? This is where strict implementation of rules set by the hospital and the country that employs the medical transcription services should be enforced. For instance, the US Department of Health and Human Services implements the Health Insurance Portability and Accountability Act or HIPAA. This US law provides privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers. The offshore provider must have clear business interest in preventing a data breach and could be prosecuted under HIPAA or other privacy laws. Some of the countries that now outsource medical transcription services are the United States and Britain, outsourcing this from countries like the Philippines, India, Sri Lanka, Canada, Australia, Pakistan, and Barbados.