The Case for Cardiology Medical Transcription Outsourcing A medical transcriptionist in the cardiology industry should be familiar with the complex terminology and procedures related to the specialty. Medical Transcription Services
Cardiology is the branch of science that deals with the study of the heart and its diseases. Transcriptionists providing cardiology medical transcription should have proper knowledge regarding the terminology, conditions, procedures and jargon specific to this specialty. Even minute mistakes in transcribing medicines, dosage and administration of vaccines may put the patient’s health and life in danger. Moreover, transcriptionists should also be familiar with various dictating styles. Cardiology has now evolved into a complex specialty with a number of new conditions identified, and a number of new procedures introduced. This evolution has also led to an increase in the types of reports that are dictated. The increasing demand for documenting cardiology reports has in turn led to increased transcription needs, which can be efficiently addressed through medical transcription outsourcing.
Complex Terminology Related to Cardiology Reports Medical transcriptionists should be well aware of the various cardiology terms so that they can create accurate cardiology reports. Reports related to cardiac conditions may contain many short forms, lengthy words, shortcuts, and word coinages that are an integral part of the language of medicine. Some of the important cardiology terms include:
Aortic root sclerosis – hardening of the aortic vessel wall connecting to the left ventricle
Bypass – to create new flow from one structure to another through a diversionary channel
Commissure – the union of two anatomical parts to form a corner
Cardiomyopathy – disease of the myocardium
Cardiac syncope – fainting with loss of consciousness resulting from any cardiac problem
Cardiopulmonary arrest – the absence of cardiac and pulmonary activity
Diaphoresis – the excretion of fluid by the sweat glands of the skin
Hypocoagulable – decreased ability of blood to coagulate or clot
Intracavitary – within a (heart) cavity
Endocardium – innermost tunic of the heart
Pericarditis – inflammation of the membrane surrounding the heart
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Cardiology Reports That Are Often Dictated History and Physical Examination – The physician gets the patient’s history and conducts a physical examination, shortly before or after a patient is admitted to the hospital. These findings that are dictated for transcription include the patient’s chief complaint, history of present illness, past medical history, family history, social history, review of systems and the physical examination. Also, a brief description of the proposed treatment plan will be dictated. Consultation – The consultation report is often dictated when the cardiologist is consulted with regard to another physician’s patient to leave an opinion about the diagnosis and treatment of a cardiac condition. This report contains a brief history of the patient’s illness, the physical findings, relevant laboratory work, a working diagnosis, and a suggested course of treatment. Operative Report – This report contains many details about the operation such as the date of operation; the duration of anesthesia and operating times; the names of the operating surgeon and assistants; the preoperative and postoperative diagnoses; the title of the operation performed; the type of anesthesia used; specimens sent to the pathology laboratory; indications for surgery; the operative findings; and a detailed description of the operation itself, complications encountered, condition of the patient at the end of the procedure, medications administered and more. Discharge Summary - Usually dictated just before or after the patient is discharged from the hospital, this medical document includes admission and discharge diagnoses, procedures or operations performed, a brief review of the patient’s history and the physician’s findings on physical examination, a report of lab tests performed and other important findings, the patient’s hospital course, discharge medications, and the discharge plan.
Cardiology Transcription in the EMR Era Now that we are in the age of electronic health records, the concept of medical transcription has changed. Rising to the position of editors, transcriptionists are providing more value-added services. Physicians attempting to do their own documentation face challenges such as copy
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pasting patient data without verifying its accuracy or relevance. This is largely due to lack of time and patience to enter the patient data into each template and field in an EHR system. It is here that the cardiology documentation services provided by a medical transcription company becomes highly significant. They ensure that exact details are filled in for each report, helping their client physicians to stay compliant with federal mandates such as Meaningful Use that demands accurate medical documentation. With an outsourcing partner, physicians need not hire additional in-house staff or stay back late to complete the medical documentation. With a good service provider that has extensive experience working with EMR/EHR systems, cardiologists are ensured HIPAA-compliant and efficient cardiology transcription and streamlined documentation. Medical transcription outsourcing will prove to be a relief for busy cardiologists.
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