Medical transcription outsourcing: Helping the clinical documentation process

In today's world healthcare facilities and healthcare professionals are increasingly faced with economic pressures, legal regulations while still providing quality healthcare services. The need of the hour is high quality, timely, patient-oriented documentation. This helps with all the concerns; economic, legal and quality healthcare. Clinical documentation is an important element of healthcare.

Clinical documentation is the process of recording and communicating a written record of the patient- healthcare professional encounter consisting of assessment, inputs from other experts if needed, the diagnosis, the treatment plan, treatment provided, the progress of the patient's response to treatment, discharge and discharge instructions. The criteria for high quality clinical documentation are legibility, completeness, clarity, consistency, precision, reliability and timeliness.  To meet all these criteria and to be efficient clinical documentation depends on narrative dictation, which then can be transcribed to be a part of the patient medical record. The process of converting the audio of the healthcare professionals' narration into text format is known as medical transcription.

Medical transcription is a specialized skill that requires the right combination of skilled medical transcriptionists, the right process and the right technology to ensure that it meets all the criteria of high quality clinical documentation. Outsourcing medical transcription has been found to be the most efficient, effective and economical means of documenting the patient- healthcare professional encounter.

How does outsourced medical transcription services help meet the criteria of quality clinical documentation?

The principles of quality clinical documentation are:

1. Legibility: The process of medical transcription ensures that the audio of the patient- healthcare professional encounter is neatly typed in the appropriate report format/template. This makes the record legible and easy to refer when required.

2. Completeness: The process of medical transcription follows HPI Quality Guidelines that specify that errors of omission are grave errors; hence efforts are made by trained and qualified medical transcriptionists to ensure that maximum possible details are captured. Moreover outsourced medical transcription service providers have quality check processes in place that put transcripts through stringent quality checks to ensure complete data is captured to the extent possible

3. Clarity: Transforming audio files into text format ensures that the details in the patient medical record are clear and unambiguous removing possibility of garbled and vague details

4. Consistency: Well trained and skilled medical transcriptionists ensure that the details captured in the medical record are consistent by applying their knowledge, context when needed and even highlighting inconsistencies for healthcare professionals to correct as and when required

5. Precision: The process of converting dictation to transcripts ensures that all details are captured accurately and everything is strictly defined.

6. Reliability: The process of outsourced medical transcription ensures that not only is the data captured accurately but also ensures security of this data during the transcription process increasing the reliability of data.

7. Timeliness: Outsourced medical transcription services ensure that by using the right blend of skilled medical transcriptionists, stringent processes and advanced technology the turnaround time requirements of healthcare professionals and healthcare facilities are met with and information is available on a timely basis.

Outsourcing medical transcription helps in the clinical documentation process, which is an essential component for efficient operations of the healthcare facility and for provision of quality healthcare.

TransDyne, a leader in the outsourced medical transcription industry has utilized their extensive background in information technology and their experience in providing medical transcription services to come up with medical transcription solutions that help healthcare facilities save on time, money and effort. TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!   

To avail complete medical transcription services from TransDyne, click here.