Ensuring Error-Free Health Care Documentation

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Ensuring Error-Free Health Care Documentation Transcribing medical notes and reports can be a real challenge. In addition to knowledge about medical terminology, it is important that the transcriptionist is well-versed in the English language including grammar, punctuation and even medical slang. Incorrect transcripts pose a potential threat to patients as they can lead to wrong conclusions and affect treatment.

Think of how dangerous it could be if the dosage of a drug in mg (milligram) is transcribed as mcg (microgram). To ensure error-free medical documents, medical transcriptionists need to have some special abilities.

Ability to Dictation

Comprehend

Mistakes

in

Physicians often make spelling mistakes. A good transcriptionist would look up doubtful terms or flag them. For instance, in a dictated report, if a physician says ‘neuroforamina’ and spells it so, the transcriptionist should know that this is a non-word and the correct term is actually ‘neural foramina’.

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Knowledge of Punctuation

English

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Language

and

The medical transcriptionists should have in-depth knowledge about the English language, usages and punctuation. You can see many MTs transcribe the word “followup” incorrectly. If this word is used as verb, it should be written as “follow up”. In all other instances, it should be written as “followup”.

Even punctuation may be dictated wrongly. They may dictate ‘comma’ after every third word even when it is not necessary. To reduce unnecessary punctuations, transcriptionists should disregard all the punctuation in the dictation and go by their own expertise to use commas and full points correctly.

For instance, physicians tend to dictate specific gravity in urinalysis as “10-10” or “10-12”, without mention of the decimal point or period. Experienced medical transcription service providers would know that “10-10” and “10-12” should be transcribed as 1.010 and 1.012. It’s therefore important that the transcriptionist learns correct punctuation for medical transcription and has the ability to correct punctuation errors and mistakes that physicians may inadvertently make in their dictation.

Excellent Proofreading Skills Proofreading or reading the transcribed documents is crucial to improve the accuracy

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of medial documentation. Most of the errors that went unnoticed at the time of the transcription process such as omitted dictated words, misinterpretation of medical abbreviations or acronyms, grammatical mistakes, punctuation errors and more can detected during proofreading. Proofreaders will actually check for the accuracy of information in transcribed medical documents, repair the transcripts, format the transcripts (for instance, convert the transcribed documents into patient charts and discharge summaries) based on the requirements of their clients to ensure the high quality medical documents.

Physician practices are faced with a deluge of dictation to transcribe and the chances of errors would be high unless the task is handled by experts. Having an in-house team on the task can prove expensive and resource consuming and that’s why most physicians rely on medical transcription outsourcing. With a team of trained and experienced transcriptionists that can handle transcription for all medical specialties as well as quality assurance specialists, a professional medical transcription company can provide quality, error-free transcripts in quick turnaround time.

http://www.medicaltranscriptionservicecompany.com

1-800-670-2809

About the Author MTS Transcription Services is an Oklahoma based secure medical transcription company, providing reliable and affordable solutions to clients across the country. It delivers quality and timely medical transcription outsourcing services within quick turnaround time.

Contact Us: Headquarters: 8596E.101stStreet,SuiteH Tulsa, OK 74133 Main:(800)6702809 Fax(877)835-5442 E-mail: info@managedoutsource.com