Is Verbatim Necessary for Medical Transcription?

Is Verbatim Necessary for Medical Transcription?

Transcribing everything word for word may not be helpful in the case of medical transcription.

Verbatim transcription means transcribing exactly what is said without making any grammatical or spelling corrections. Everything from false starts to sentences including stutters and redundant words is transcribed in this type of transcription. A true verbatim transcript transcribes everything on the audio files as it is. But is this necessary while transcribing physician’s dictations?

The aim of medical records is to provide precise and clear data about the history and the present condition of the patient’s health, treatment, contraindications and future treatment plans. Transcribing everything word for word may not be helpful in the case of medical transcription.

The Practical Approach Physicians can dictate from anywhere with the dictation technology available today but they may be distracted by noises and activities in the environment that may lead to mistakes while dictating. Dictation may also have background noises going that can cause disturbance. This makes it difficult for the medical transcriptionist to distinguish between some words and phrases.

Professional transcriptionists are trained in various diseases, diagnoses, treatments and medical terminology and a good transcriptionist uses logic and judgment when transcribing a physician’s notes. When transcribing dictated medical notes it is best to transcribe word to word with reasonable logic i.e., making necessary changes that would not in any manner affect the details regarding the patient’s health condition and treatment. The transcriptionists have to edit, also make corrections and contact the physician if necessary in case of any doubt or need for clarification.

Important Considerations The following guidelines can be considered when transcribing physician’s dictated notes.  Follow the dictator’s style of dictation and correct grammatical errors and spelling mistakes without changing the meaning of the dictated notes.  Expand abbreviations that are a part of the treatment and the diagnosis

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 Eliminate exact redundancies  The heading should be transcribed as it is  Consult the concerned physician if any major editing is required or if there is any doubt of incorrect terminology or other ambiguity  Also, bring any contradictory or questionable information to the physician’s notice immediately With the help of a reliable medical transcription service provider, physicians can obtain timely and accurate patient records. The trained and experienced transcriptionists in a medical transcription company are well-versed in the latest software and technology that can deliver good quality output. The best thing about having such outsourced support is that physicians can benefit from insightful medical transcription that provides a clear idea of the patient’s health condition, treatments provided, details regarding providers and all other important information necessary for providing optimum care to the patient.

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800 – 670 - 2809