Possible Errors in Medical Transcription and How to Avoid Them
Transcribing medical notes and reports should be done with at utmost care and accuracy as even a small error in medical transcription can endanger patient safety and the integrity of the documentation. The job requires excellent knowledge of medical terminologies as well as of the English language, grammar, punctuation, abbreviations, capitalization of drug names, and even medical slang. Errors, whether critical or non-critical, can lead to wrong conclusions and treatment. Let us take a look at some of the common and potential errors that medical transcriptionists are prone to commit and how these mistakes can be avoided.
Common Errors in Medical Transcription Errors in medical transcription can be categorized under two main headings
Critical Errors: Critical errors are more serious as they can affect patient safety, care, or treatment. These errors can happen due to
Terminology Misuse: An incorrect medical terminology can lead to inaccurate diagnosis, incorrect medical decision, as well as inaccurate medical billing. For example, use of the word „access‟ which means „admittance‟, instead of „excess‟ which means „beyond the usual‟, as in “Excess peritoneal fluid was present.”
Omissions/Insertions: Omitted or added words can compromise patient safety. For example, if the original dictation of „The patient is on 40mg of „esomeprazole‟ is wrongly transcribed as „The patient is on 400mg of „esomeprazole‟!
Incorrect Patient Demographics: Errors may also occur with regard to patient encounter information such as date of service, date of consultation, medical record number, date of operation, and author identification number.
Non-Critical Errors: Non-critical errors do not change the meaning of the dictation and cannot directly affect patient care and safety. It can be due to
Misspelling: Error occurs due to misspelled words can affect the integrity of the document. Eg: „Erythema‟ as „Erythemia‟
Incorrect Verbiage: Transcription with inappropriate or excessive editing did not produce a significant impact on medical meaning, but should be considered as an error.
Errors can also occur when the medical transcriptionist fails to follow protocol, fails to flag a report for clarification, and fails to follow account specifications related to formatting or document preparation.
Skills Required to Avoid Medical Transcription Errors
Ability to Comprehend Mistakes in Dictation: It‟s quite natural for physicians to make
spelling
mistakes
while
dictating.
Medical
transcriptionist
should
be
knowledgeable enough to correct the incorrect terms or they should flag them For instance, in a dictated report, if a physician has quoted „neuroforamina‟ for „neural foramina‟, transcriptionist should be skillful enough to correct it. Knowledge of English Language and Punctuation: The medical transcriptionists should
have
in-depth
knowledge
about
the
English
language,
usages
and
punctuation. For example, they should know the difference and usage of words, „follow up‟ and „followup‟, it should be written as „follow up‟ when used as a verb and in other instances as „followup‟ which is a noun. Excellent Proofreading Skills: Proofreading or checking the transcribed documents for accuracy is also important. Errors that went unnoticed during transcription phase can be identified in the proofreading stage. Common errors identified in this stage include:
Grammatical mistakes
Misinterpretation of medical abbreviations or acronyms
Omitted dictated words
Punctuation errors
Proofreaders will check for accuracy, and repair and format transcripts based on client requirements. There are high chances of errors in medical transcription if the task is not handled by experts. Associating with a professional medical transcription company with a team of trained and trained and experienced transcriptionists can reduce the number of errors and processing time.