MT (Medical Transcription) professionals can never take it easy on their job. They have to be always alert as they just cannot afford to make any mistakes in documentation. All medical patient documents have to be totally error free because errors in documentation can result in,
- Risk to the patient’s health/ life
- Risk of malpractice suit to the health provider/ physician
The HIPAA (Health Insurance Portability and Accountability Act) realizes that for reasons of security and to simplify the transcription process it is required to make the maximum use of electronic data and digital communication. A high standard has to be maintained by the medical transcription service providers.
Besides technical perfection, the medical transcriptionist must have expertise and knowledge of medical terminology, human anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values, including proficiency in English usage, grammar and punctuation. The AAMT Book of Style is the industry standard and the American Association for Medical Transcription recommends the following quality goals: 100% accuracy with respect to critical errors; 98% accuracy with respect to major errors; and 98% accuracy with respect to all errors in the report, including minor errors.
How can the quality principles be implemented in an MT unit? Here are a few important points that must be implemented for producing medical documentation with the bare minimal error.
- Reports transcribed by new MTs must be reviewed more frequently
- Random review to be conducted
- 3 to 5 percent sampling
- Define minor and major errors
- Ongoing feedback, education, and performance improvement
- Develop a transcriptionist's experienced judgment
The author of this article is Ricci Mathew of OSI (Outsource Strategies International ), a US based company that offers services in Medical Coding, Medical Billing and Medical Transcription for clients across the US.
