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Medical transcription--MT is part of the healthcare industry that renders and edits doctor dictated reports, procedures, and notes in an electronic format in order to create files representing the treatment history of patients. Health practitioners dictate what they have done after performing procedures on patients and MT’s transcribe the oral dictation and/or edit reports that have gone through speech recognition software. Pertinent up-to-date, confidential patient information is converted to a written text document by a medical transcriptionist--MTs. This text may be printed and placed in the patient's record and/or retained only in its electronic format. MT can be performed well by independent contractors for a service company that performs the work offsite under contract to a hospital, clinic, physician group or other healthcare provider. Hospital facilities often prefer electronic storage of health records due to the sheer volume of hospital patients and the accompanying paperwork. The electronic storage in their database gives immediate access to subsequent departments or providers regarding the patient's care to date, notation of previous or present medications, notification of allergies, and establishes a history on the patient to facilitate healthcare delivery regardless of geographical distance or location. The term transcript or "report" as it is more commonly called and is used as the name of the document (electronic or physical hard copy) which results from the MT process, normally in reference to the healthcare professional's specific encounter with a patient on a specific date of service. This report is referred to by many as a “health record". Each specific transcribed record or report, with its own specific date of service, is then merged and becomes part of the larger patient record commonly known as the patient's health history. This record is often called the patient's chart in a hospital setting.
Medical records have been kept since humans began writing, as attested by ancient cave writings. MT as it is currently known has existed since the beginning of the 20th century, when standardization of health data became critical to research. At that time, health stenographers replaced physicians as the recorders of health information, taking doctors' dictation in shorthand. With the creation of audio recording devices, it became possible for physicians and their transcriptionists to work asynchronously, thus beginning the profession of healthcare documentation as we currently know it. Over the years, transcription equipment has changed from manual typewriters to electric typewriters to word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings. Today, speech recognition (SR), also known as continuous speech recognition (CSR), is increasingly being used, with Medical Transcriptionists--MTs and or "editors" providing supplemental editorial services, although there are occasional instances where SR fully replaces the MT. Natural-language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide (although MTs do). In the past, these health reports consisted of very abbreviated handwritten notes that were added in the patient's file for interpretation by the primary physician responsible for the treatment. Ultimately, this mess of handwritten notes and typed reports were consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the health records department. Whenever the need arose to review the records of a specific patient, the patient's file would be retrieved from the filing cabinet and delivered to the requesting physician. To enhance this manual process, many health record documents were produced in duplicate or triplicate by means of carbon copy. In recent years, health records have changed considerably. Although many physicians and hospitals still maintain paper records, there is a drive for electronic records. Filing cabinets are giving way to desktop computers connected to powerful servers, where patient records are processed and archived digitally. This digital format allows for immediate remote access by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises. Many MTs now utilize personal computers with electronic references and use the internet not only for web resources but also as a working platform. Technology has gotten so sophisticated that MT services and MT departments work closely with programmers and information systems (IS) staff to stream in voice and accomplish seamless data transfers through network interfaces. In fact, many healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants (PDAs) and are now utilizing software on them.
When the patient visits a doctor, the latter spends time with the former discussing his health problems, including history and/or problems. The doctor performs a physical examination and may request various laboratory or diagnostic studies; will make a diagnosis or differential diagnoses, then decides on a plan of treatment for the patient, which is discussed and explained to the patient, with instructions provided. After the patient leaves the office, the doctor uses a voice-recording device to record the information about the patient encounter. This information may be recorded into a hand-held cassette recorder or into a regular telephone, dialed into a central server located in the hospital or transcription service office, which will 'hold' the report for the transcriptionist. This report is then accessed by MTs, it is clearly received as a voice file or cassette recording, who then listens to the dictation and transcribes it into the required format for the health record, and of which this health record is considered a legal document. The next time the patient visits the doctor, the doctor will call for the health record or the patient's entire chart, which will contain all reports from previous encounters. The doctor can on occasion refill the patient's medications after seeing only the health record, although doctors prefer to not refill prescriptions without seeing the patient to establish if anything has changed. It is very important to have a properly formatted, edited, and reviewed MT document. Both the doctor and the MTs play an important role to make sure the transcribed dictation is correct and accurate. The doctor should speak slowly and concisely, especially when dictating medications or details of diseases and conditions. The MTs must possess hearing acuity, health knowledge, and good reading comprehension in addition to checking references when in doubt. The MTs is bound to transcribe verbatim (exactly what is said) and make no changes, but has the option to flag any report inconsistencies. On some occasions, the doctors do not speak clearly, or voice files are garbled. Some doctors are, unfortunately, time-challenged and need to dictate their reports quickly (as in ER Reports). In addition, there are many regional or national accents and (mis)pronunciations of words the MTs must contend with. It is imperative and a large part of the job of the MTs to look up the correct spelling of complex health terms, medications, obvious dosage or dictation errors, and when in doubt should "flag" a report. A "flag" on a report requires the dictator (or his designee) to fill in a blank on a finished report, which has been returned to him. All transcription reports must comply with medico-legal concerns, policies and procedures, and laws under patient confidentiality. In transcribing directly for a doctor or a group of physicians, there are specific formats and report types used, dependent on that doctor's speciality of practice, although history and physical exams or consults are mainly utilized. MT’s, performing document typing and formatting functions according to an established criteria or format, transcribing the spoken word of the patient's care information into a written, easily readable form. MT requires correct spelling of all terms and words, (occasionally) correcting medical terminology or dictation errors. MTs also edit the transcribed documents, print or return the completed documents in a timely fashion. Medicine is constantly changing. New equipment, new medical devices, and new medications come on the market on a daily basis, and the MTs needs to be creative and to tenaciously research (quickly) to find these new words. MTs need to have access to, or keep on memory, an up-to-date library to quickly facilitate the insertion of a correctly spelled device.
See our transcribing steps. Step 1: Dictating the information: The MT process begins with the physician recording patient-related information into a digital recording device, such as a PC, a hand-held digital recorder, a cassette recorder, an analog recording device or a phone-in recorder. It is very important to use a good recording device, as it can have a direct impact on the quality of the recording, and may thereby affect the accuracy of the transcribed documents. Do choose a digital recording device as it will offer superior voice quality and clarity when compared to an analog recorder. You can also install specialized voice recording software modules in your PC. Step 2: Transmitting the voice files: Once the voice files are recorded, you can directly upload them to our company. Our MTs will immediately download the voice files and start transcribing them. By directly accessing your voice files, we can provide fast MT services on a 24/7 basis, without any time delays. Step 3: Transcribing the voice files into text: In this stage, the downloaded voice files are assigned to our experienced team, who convert them into word processing documents. Headphones are used to listen to the dictated notes, and foot-pedals are used to replay the voice files. Each voice file is given a unique job ID, so that the same file is not sent to two different transcribers. The voice files will be typed verbatim without any modifications. Editing will be kept to a minimum, with only obvious grammatical and usage errors getting corrected. If a particular voice file is incomplete, unclear or inconsistent, our MTs will immediately request for the relevant physician's comments on the same. Our MTs extensively research on the internet and refer to printed and online medical dictionaries to overcome problems with unfamiliar medication names, unknown terminology, unclear enunciations, or poor voice quality in the recording. Step 4: Editing and reviewing the transcribed files: Once the work is completed, the text files will be sent to our team of experienced editors who will proofread the document in its entirety. The transcribed files are thoroughly checked to identify omissions and eliminate even the smallest of errors. We check the accuracy of the data, along with the corresponding dates. Special attention is paid to the prescribed format and other applicable standards. Our thorough editing process enables us to provide physicians with 99.9% accurately-transcribed files with zero errors. After our editing process is completed, the transcribed files are sent to be reviewed by the originating physician. At this stage, comments about inconsistencies will be checked by the relevant physician. Corrections, if needed, will be made by our transcribers. Step 5: Sending the completed transcribed files in real-time: The edited, reviewed and corrected documents will be sent to the customer.
Why hire us for MT services? You can be assured about the privacy and confidentiality of patient information, as we use secure servers, 128/256-bit encryption and third party certification while downloading files. We also ensure the secure exchange and storage of files; Our transcriptionists work on state-of-the-art dictation technology and infrastructure, along with the latest transcription software and methodologies to provide fast and 99.9% accurate transcriptions everyday. Our MT team comprises of experienced language specialists, with a thorough knowledge of health terms, expertise in the English language and exceptional typing and listening skills; We have over 10 years of experience in transcribing, formatting, editing and proofreading health documents for healthcare facilities in the US, UK, Canada Australia and for clients across the world.
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