Better Clinical Documentation -- How Medical Transcriptionists Can Help Utilize Speech Recognition S

Better Clinical Documentation How Medical Transcriptionists Can Help Utilize Speech Recognition Software

Speech recognition tools allow physicians to deal with point-to-click boxes and drop down menus in EHRs better. They allow dictated notes to be automatically formatted into EHRs. One may think that this would eliminate the need for medical transcription specialists. But actually this would change their role from creating medical documents to reviewing and editing documents created using speech recognition technology, thereby improving the accuracy of clinical documentation.

Before exploring this interesting fact, let’s take a detailed look at the benefits of speech recognition software.

Advantages of Speech Recognition Software 

Speech recognition software helps physicians enter patient data into the EHR using commands instead of using keyboards. This will save their time required for documentation, enable fast access to documents and eventually ensure better patient care and productivity.

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Since physicians can simply perform their documentation through dictation, they can engage more with the patient and provide them with the required instructions and advice.

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Physicians often cut and paste their notes from previous ones within the electronic record system to save their time. This could be very dangerous as these notes become much harder to defend if they are not updated as necessary and checked thoroughly for consistency. With speech recognition system, physicians can dictate patient details each time and reduce the need for copy-pasting.

Role of Medical Transcriptionists As mentioned earlier, medical transcriptionists now play a different role as editors.

As no physician can ensure absolutely perfect dictation and it is important to keep the narrative quality of reports in certain cases, editing for clarity and consistency is still required while using speech recognition software and this job can be done effectively by medical transcriptionists. They can interpret medical terminologies and abbreviations in patients’ medical histories, discharge summaries, surgery reports and other documents and edit the following appropriately. 

Sometimes, the physician’s dictation won’t be clear enough for the software to capture spoken words (if the physician is tired or speak hurriedly). On the other hand, experienced transcriptionists can understand what terms they would have used as they have sufficient expertise in the industry and use the correct words to complete the records.

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Foreign accents and speech patterns may be difficult for the software to interpret, which can be identified accurately with the help of professional transcriptionists.

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Unlike speech recognition software, transcriptionists can check the use of appropriate grammar, punctuation or the right words within the reports to express the correct meaning.

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The software may have captured inaudible words as wrong terms, which can be recognized by transcriptionists and flagged for physicians to review.

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Transcriptionists can correct transpositions of test values or medication dosage inconsistencies if any, during the process of reviewing and editing.

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There may be contradictory details within dictated notes, which can be resolved by the transcriptionists during reviewing.

To put it in a nutshell, transcriptionists can help to overcome the limitations of speech recognition software and generate accurate and complete documentation with fast turnaround times. However, the medical transcriptionists that you choose to edit your records generated through speech recognition system should have the following qualities. 

They must be thoroughly knowledgeable in medical terminology, anatomy and

physiology,

pharmacology,

diagnostic

procedures

and

treatment

assessments. 

They should ideally be familiar with EHR systems as well with the ability to enter reports, create templates and help in developing documentation policies.

Physician practices should either train their transcriptionists for that or take help from professional medical transcription companies that provide three-level quality assessment involving proofreaders and editors.