TIPS TO MINIMIZE DICTATION ERRORS
Quality is of utmost importance in medical transcription. Effective documentation of patient records depends greatly on dictation quality. Finding errors during a physician dictation is not uncommon, whether it is human error (caused by entering incorrect patient medical record number or date of service), low quality audio from heavy background noises, or recording equipment malfunction. No matter how qualified or experienced the physicians are or how many medical miracles they perform, dictation errors are likely to happen. It is not practical to expect that dictation errors can be completely eliminated. There are different variables involved of which human error is one of the most important factors. Speech recognition software cannot produce 100% accurate and precise transcripts. Medical transcriptionists or health care documentation specialists cannot remain irresponsible for these errors. Though they may not be completely responsible for creating these errors, it is their duty to clearly identify the same. The future consequences of any type of dictation error can sometimes be minimal or life threatening. Hence, dictation errors can have a significant impact on patient health care. For instance, Roxanol is a concentrated solution of morphine sulfate for oral administration. If the doctor wrongly overhears the dosage from 100 mg of Roxanol every four hours instead of 10 mg every four hours, the end results can prove to be deadly.
Important Tips for Accurate Medical Transcription Clinical dictation is all about communicating the patient’s health history for the next provider that’s going to be a significant part of patient care experience. The future treatment plans or decision about what further testing patients should undergo is made during this stage. While looking at the breakneck pace at which technology evolves and with the health system becoming more interoperable, even a single error can directly impact patient care, billing and data integration. Though medical dictation errors are unavoidable, there are different ways in which medical transcriptionists can deal with the different factors that enhance the chances for errors. Here are some tips to ensure an accurate medical transcription even when dictation quality is poor:
Recheck Transcripts - Proofreading a final transcribed document is an important step in identifying medical transcription errors. Reliable medical transcription companies employ the services of quality control team like editors, medical experts and proof readers who checks the transcripts to identify errors. Along with this, certain other information like patient names, medical record numbers and dates are double checked.
Knowledge About Medical Terminology - A qualified medical transcriptionist should have in-depth background knowledge about several medical metrics like anatomy and physiology, lab and radiology values, surgical and other important medical terminologies. An experienced medical transcriptionist should have a correct understanding about different lab value parameters, medicine dosages and what makes sense. For example, if a doctor dictates that a particular patient has hypokalemia but his potassium level is 8. 1, a good transcriptionist should have the relative knowledge that these two statements do not correlate. A qualified and experienced medical transcriptionist should have complete medical knowledge about the following –
What drugs work for what indication
Normal lab values to recognize outliers
Good training and superior knowledge of medical language, diagnostics, medications and disease processes
Correct context for common homonyms
Age-related ailments
A comprehensive understanding of anatomy and physiology to know the exact context of the body part or system described in the dictation
Use Reference Tools - If any case, if the transcriptionist has any doubt related to any piece of dictation, it is essential to search for a reference tool. Refer a drug book to check whether the dosage for a particular medication is available and whether it is correct for the patient and situation. Also, referring previous documents by a dictator in question can also give enough context and clues to resolve a particular medical doubt.
Sharpen Listening Skills - In order to deliver accurate and precise transcripts, the documentation specialist needs to have good listening skills. It is always better to listen to the dictation as a whole entity rather than in different parts as this will ensure accuracy. Always not listen or just not focus on words but be alert on what the physician meant to say. In certain cases, there will be heavy background noises either in the dictation or within the office environment which may prevent the transcriptionist from clearly hearing the physician’s voice. Hence, transcriptionists need to sharpen their listening and concentration skills to deliver correct transcripts.
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Partner with Physicians - Transcriptionists, in most cases, may be apprehensive about addressing physicians with dictation issues for fear that they will be viewed as inefficient. However, if health care documentation specialists approach physicians with dictation problems more proactively this will help to create more accurate patient records. There are several ways in which transcriptionists can partner with physicians to create improved documentation on the front end. Do share bloopers in medical staff meetings to accentuate the value of good habits. Also, publish the average speech recognition scores for entire organization and then privately share the specific scores with each physician so that they can analyze what they stand for.
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No Guess Work - It is better for transcriptionists to leave a blank space in the final transcript than indulge in guess work of some terms which they are not 100% sure. In such cases, transcriptionist can flag the specific portion in the document and later clarify it with the physician or QA reviewer.
Medical transcriptionists need to continue their learning to keep updated about the different changes in medical terminology or documentation. Continuous education and training related to this field are proactive steps which medical transcriptionists can do to minimize errors. Gaining experience in the field of medical transcription will help transcriptionists to become familiar with the medical jargon and to recognize correct and incorrect dictation. Professional medical transcription companies have a trained team that can do all of this and more.
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