Medical Transcription: Role Played In Healthcare

Medical transcription is a very important part of the healthcare cycle and plays an important role in both the operational and commercial aspects of healthcare.

· Role of medical transcription in the operational aspect of healthcare: When a patient visits a healthcare professional, it could be for various reasons like an emergency, sudden illness, regular visit or continuation of an ongoing treatment plan. These visits need to be documented as part of the patient’s records.

Not only does this information form a permanent part of the patient’s health record, it forms a foundation for future encounters. Factors like demographics, lifestyle of the patient, past medical history, past treatment/procedures availed, past medications, allergies etc., have an effect on the future treatment plan.

In case the patient is availing a new mode of treatment, which is in the experimental stages, this information needs to be captured for record and research purposes. In case of any findings from the tests conducted require further treatment, the record forms the basis of referral to a specialist. Medical records enable the healthcare professional to take informed decisions instead of relying on memory or guesswork by creating accurate and timely records.

· Role of medical transcription in the commercial aspect of healthcare: The secondary, but equally important role played by patient medical records are the commercial aspect. Patient records form the basis of claiming payment from the insurance company. The information from the record created by the transcription process is used as the basis of coding, billing and insurance claims. Any delays in the record creation process could adversely affect the receivables cycle.

Medical records also provide evidence in case of any litigation issues and it is also a statutory requirement to maintain patient records for a certain period of time. Medical transcription plays an important part in record creation by capturing all the information of the patient-healthcare professional encounter.

· Where does the process begin?
The process begins when the patient enters the healthcare facility for availing treatment. The front office collects details like date of birth, gender, Social security no., employer details and details of the policy name and number etc. The patient meets the healthcare professional for consultation and treatment. This total encounter is dictated into a recording device by the healthcare professional. The audio recordings are then transmitted to the service provider for transcription.

· What are the various stages in the process?
The audio records are downloaded at the service provider’s site and distributed for transcribing among the transcriptionists based on their expertise. Once the transcription process is over, the proofreader goes through the record to ensure accuracy and fill any gaps, which are left blank. Then the files are passed on the Unit in charge who goes through the record once more to ensure accuracy. Before finally transmitting to the client the quality assurance does random checks to ensure total quality and the final corrections are made if required.

· What are the attributes that define quality transcription?
The attributes that define quality are:
a. Accuracy: Needs to be above 99%
b. Turnaround time: Needs to be within 24 hours
c. Price: Needs to be reasonable and fair
d. Security: Has to cover all aspects that are, technology, infrastructure, people and processes.
e. Technology: Needs to be easy to use and provide maximum benefits.

It is important to have medical transcription support for both the operational and commercial aspects of healthcare. At the same time one needs to have the right provider to have benefits like accuracy, turnaround time, price, security and the right technology for ease of use.