How Can You Avoid Errors In Medical Transcription
www.medicaltranscriptionservicecompany.com
Electronic health record systems and the use of voice dictation software are changing the face of medical transcription. Regardless of these changes, accuracy and timeliness in documentation is crucial to ensuring the quality of care and adherence to statutory regulations.
When
a
physician
dictates
and
the
medical
transcriptionist converts the audio file into a text document, there is always
the
chance
transcription
that
endanger
documentation.
errors patient
Inadvertent
will
occur.
safety
mistakes
and
Errors the
have
in
medical
integrity
even
had
of
fatal
consequences.
Reasons why Medical Transcription Errors occur
1
Inexperience with medical terminology
It is important that the transcriptionist has in-depth knowledge about medical terms, jargon and abbreviations. Physicians often use short forms for making patient notes and expect the transcriptionist to know what these stand for and to note them correctly when typing out a detailed transcript. As medical field is advancing with new treatments and processes, it is essential for a transcriptionist to
stay
updated
documentation.
with
the
latest
medical
terminology
to
ensure
precise
2
Failure to understand the voice recording There may be physicians with heavy accents as well as those who do speak clearly or too fast into the digital recorder. Heavy background noises can overpower the doctor’s voice in the recording and affect audibility, which in turn can cause errors in the typed record. The transcriptionist must also be able to make out heavily accented speech.
3 Spelling errors This
may
occur
with
both
equipment
and
medication
names.
Wrong
capitalizations, same sounding words, or word hyphenations are part of spelling errors. Transcriptionists would need to research online or refer to a medical compendium when they are not sure about something.
4
Failure to make a good judgment The job of a medical transcriptionist also involves arranging important documents so that healthcare professionals can refer to them while treating patient.
Their
job
also
involves
flagging
a
medical
report,
correcting
information, and doing comprehensive research to fill in the blanks. If, by any chance, transcriptionists are not able to understand a specific medical term or phrase, they should not try to guess the same as this can result in error and cause serious harm to the patient and the reputation of the health care provider.
5 Inadequate proofreading of dictated reports Proofreading and quality assurance checks are essential to ensure accurate transcripts. Quality assessment is very important to ensure if the report has been correctly transcribed. In leading medical transcription companies, multilevel quality checks are conducted before the final transcript is submitted. This ensures that healthcare documentation is accurate, complete and clear.
6 Dosage errors Transcription errors are considered to be “critical” when they can have serious or life threatening consequences which may impact patient safety. For instance, in one case, Sharron Juno, a female diabetic patient died because of a typo. The doctor dictated that the patient was to be given 8 units of insulin, but the transcriber wrote it as “80 units” instead. The patient was given 10 times the dosage as the doctor had specified and she died. The outcome of the transcriber’s mistake was irrevocable.
There is a view that implementation of a computerized physician order entry system
(CPOE)
and
electronic
documentation
can
reduce
the
chances
of
transcription based errors. However, experience shows that errors can only be avoided by cross-checking data and attention to detail.
How to Avoid Transcription Errors
Physicians can ensure error-free documentation in the following ways:
Select top quality digital recording equipment that offers the best sound quality and clarity
Employ the services of a professional medical transcription company
Make sure that medical transcription service has proofreading and quality assurance
checks in place to detect and correct errors at an early stage
Ensure that the service provider has a well-trained and qualified team of medical transcriptionists who are well versed in medical terminology and jargon and have language skills.
With new healthcare laws, implementation of electronic health records, and transition to ICD-10, physicians are busier than ever. Partnering with the right medical
transcription
company
is
crucial
to
ensure
error-free
documentation for higher levels of productivity and efficiency.
and
timely
Contact MTS Transcription Services
Headquarters: 8596 E.101 Street, Suit H Tulsa, OK 74133 Main: (800) 670 2809 Fax: (877) 835-5442