Healthcare services by their very nature are complex and require inputs from various sources to be effective and meet the stringent standards of quality required by them. One of the main inputs that healthcare professionals and healthcare facilities depend on for providing quality healthcare and for the smooth running of the healthcare facility is information from patient records. Information can be defined as the fundamental input that keeps the healthcare facility efficient both in terms of providing quality healthcare and accelerating reimbursements.
Medical transcription is the process of creating patient medical record transcribing the audio files of the patient- healthcare professional encounter into text format. These patient medical records form the basis for the smooth running of the healthcare facility.
What is a patient medical record?
The medical record can be defined as a document containing comprehensive and factual information regarding the patient's health status, the diagnoses based on the information and the treatment provided. The medical records would also reflect the response to treatment, subsequent visits and treatment provided. Medical records also provide information regarding tests, X-rays, laboratory work etc along with communication and findings from other healthcare professionals.
What is the purpose of maintaining medical records?
Medical records are valuable as a source of information and provide support in the following:
- Patient medical records provide information regarding the treatment process, which can then be used to communicate with the various parties involved in providing care including healthcare professionals, employers, insurance companies and the patients themselves.
- Patient records provide information that help evaluate the adequacy and appropriateness of care.
- Patient medical records are important for planning the course of care in case of prolonged illness requiring long term treatment
- Patient medical records provide evidence in case of litigation
- The information in patient medical records can be used for research and education purposes.
It can be seen that patient medical records provide vital support to the smooth running of healthcare facilities aiding the healthcare process and accelerating the reimbursement process. Outsourcing medical transcription has been found to be an effective and economical solution for healthcare facilities looking to ensure accurate, timely, secure and cost effective creation of patient medical records.
However while outsourcing medical transcription, healthcare facilities have to evaluate the medical transcription service provider based on the following criteria:
- Accuracy: This means the percentage of accuracy of the completed transcripts vis-à-vis what was dictated. A minimum of 99% and above would be acceptable. It is important to choose a medical transcription service provider that executes all the medical transcription work in-house using skilled and trained medical transcriptionists and having a quality assurance process involving several checks
- Turnaround time: Turnaround time refers to the time taken to revert the transcribed report to the healthcare facility. The medical transcription service provider needs to offer options for turnaround time that can be tailored to meet the needs of the healthcare facility. The acceptable turnaround time option is 24 hours for normal reports and 4-12 hours for STAT reports.
- Security: The service provider being outsourced to should be HIPAA and HITECH compliant. The medical transcription service provider has to have adequate security measures to ensure that the confidential data transmitted back and forth is safe and secure.
- Pricing: Reduced cost of transcription is one of the main benefits that a healthcare facility hopes to have, from the outsourcing option. Pricing should be fair and reasonable for the services rendered. Billing methods used by medical transcription service providers are varied and should meet the criteria of being measurable, verifiable, definable, consistent and fair & honest.
- Technology: The technology used by the medical transcription service provider should not only secure but should also be easy to use, without having to require extensive training.
TransDyne, a leader in the outsourced medical transcription industry provides complete medical transcription solutions. 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!
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