How Can You Avoid Errors in Medical Transcription

How Can You Avoid Errors In Medical Transcription

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Electronic health record systems and the use of voice dictation software are changing the face of medical transcription. Regardless of these changes, accuracy and timeliness in documentation is crucial to ensuring the quality of care and adherence to statutory regulations.

When

a

physician

dictates

and

the

medical

transcriptionist converts the audio file into a text document, there is always

the

chance

transcription

that

endanger

documentation.

errors patient

Inadvertent

will

occur.

safety

mistakes

and

Errors the

have

in

medical

integrity

even

had

of

fatal

consequences.

Reasons why Medical Transcription Errors occur

1

Inexperience with medical terminology

It is important that the transcriptionist has in-depth knowledge about medical terms, jargon and abbreviations. Physicians often use short forms for making patient notes and expect the transcriptionist to know what these stand for and to note them correctly when typing out a detailed transcript. As medical field is advancing with new treatments and processes, it is essential for a transcriptionist to

stay

updated

documentation.

with

the

latest

medical

terminology

to

ensure

precise

2

Failure to understand the voice recording There may be physicians with heavy accents as well as those who do speak clearly or too fast into the digital recorder. Heavy background noises can overpower the doctor’s voice in the recording and affect audibility, which in turn can cause errors in the typed record. The transcriptionist must also be able to make out heavily accented speech.

3 Spelling errors This

may

occur

with

both

equipment

and

medication

names.

Wrong

capitalizations, same sounding words, or word hyphenations are part of spelling errors. Transcriptionists would need to research online or refer to a medical compendium when they are not sure about something.

4

Failure to make a good judgment The job of a medical transcriptionist also involves arranging important documents so that healthcare professionals can refer to them while treating patient.

Their

job

also

involves

flagging

a

medical

report,

correcting

information, and doing comprehensive research to fill in the blanks. If, by any chance, transcriptionists are not able to understand a specific medical term or phrase, they should not try to guess the same as this can result in error and cause serious harm to the patient and the reputation of the health care provider.

5 Inadequate proofreading of dictated reports Proofreading and quality assurance checks are essential to ensure accurate transcripts. Quality assessment is very important to ensure if the report has been correctly transcribed. In leading medical transcription companies, multilevel quality checks are conducted before the final transcript is submitted. This ensures that healthcare documentation is accurate, complete and clear.

6 Dosage errors Transcription errors are considered to be “critical” when they can have serious or life threatening consequences which may impact patient safety. For instance, in one case, Sharron Juno, a female diabetic patient died because of a typo. The doctor dictated that the patient was to be given 8 units of insulin, but the transcriber wrote it as “80 units” instead. The patient was given 10 times the dosage as the doctor had specified and she died. The outcome of the transcriber’s mistake was irrevocable.

There is a view that implementation of a computerized physician order entry system

(CPOE)

and

electronic

documentation

can

reduce

the

chances

of

transcription based errors. However, experience shows that errors can only be avoided by cross-checking data and attention to detail.

How to Avoid Transcription Errors

Physicians can ensure error-free documentation in the following ways:

Select top quality digital recording equipment that offers the best sound quality and clarity

Employ the services of a professional medical transcription company

Make sure that medical transcription service has proofreading and quality assurance

checks in place to detect and correct errors at an early stage

Ensure that the service provider has a well-trained and qualified team of medical transcriptionists who are well versed in medical terminology and jargon and have language skills.

With new healthcare laws, implementation of electronic health records, and transition to ICD-10, physicians are busier than ever. Partnering with the right medical

transcription

company

is

crucial

to

ensure

error-free

documentation for higher levels of productivity and efficiency.

and

timely

Contact MTS Transcription Services

Headquarters: 8596 E.101 Street, Suit H Tulsa, OK 74133 Main: (800) 670 2809 Fax: (877) 835-5442