The healthcare process is complex one depending on inputs from various sources to be effective and economical. Medical transcription has always played an important part in the delivery of healthcare by creating patient records from the audio records of the patient- healthcare professional encounter.
The importance of this service as a link in the process of delivering quality healthcare can be understood by studying in detail, the information captured in patient records. Patient records contain the following:
The patient demographic sheet or hospital admission sheet:
This includes details like
Patient's address
Next of kin
Birthplace
Social security number
Occupation
Sex
Marital status
Ethnic origin
Religious preference
Admitting diagnosis
Financial entries including:
Patient's employee
Job title
Address of company
Insurance company
Contact person for emergency
Type of coverage
Insurance Identification number
Type of payment plan.
Consent forms Include:
Patient's consent for treatment
Outline of patient's responsibilities including billing
Assurance that confidentiality will be protected
Medical entries of the patient's healthcare records include:
Physician's notes
Diagnostic tests
Nursing entries
Physician entries
Therapists entries
Ancillary personnel entries
Emergency records include:
Demographic details
Nursing assessment
Physician's evaluation
Treatment
Conclusions
The role that patient medical records play in the process of healthcare is vital. As comprehensive records include:
Diagnostic test results
Consent
Instructions
The role of medical transcription is that of recording the symptoms, the diagnosis, the treatment process and the progress made by the patient. This helps healthcare professionals in providing quality healthcare and also helps in the process of coding and billing. An easy fix to ensure that medical transcription takes place in a speedy, accurate, cost-effective manner and secure manner is to outsource the process of medical record creation to a professional transcription vendor.
Some of the advantages of outsourcing are:
Increase in productivity: This has the advantage of increasing productivity of healthcare professionals and other staff in the healthcare facilities by providing services with several time saving benefits like:
1. Retaining familiar modes of dictation
2. Automatic uploads and downloads
3. Providing multiple options for document delivery
4. Archives to enable tracing transcripts
5. HL7 interface for EMR adoption
Decrease in costs: Availing services from an outside entity benefits the healthcare facilities by providing enormous savings on costs; both direct and indirect
Streamlined process: This also ensures that the process of patient medical record creation occurs on a regular basis, ensuring both accuracy and turnaround time and in formats/templates required by the healthcare facilities/ healthcare professionals.
Healthcare facilities benefit by the administrative expertise, the technological expertise and the best practices of the transcription vendor.
Renee Kelly has written numerous articles on transcription, which has served as an amazing resource for healthcare facilities and healthcare professionals seeking medical transcription.
