Everything You Need to Know About Transcribing Medical Records
Medical record transcription is the process of typing a medical report from an audio file that a doctor, nurse, or other healthcare professional might have dictated. Healthcare professionals such as doctors, nurses, practitioners, surgeons, and others have challenges to face. Throughout the day, they are on the move, assisting the patients under their care as best as they can.
However, a ton of paperwork may stand as an obstacle in their way of providing better service. In fact, many healthcare professionals end up frustrated or annoyed at spending so much of their valuable time attending to paperwork-related obligations instead of their patients. In this article, we will cover medical records and how outsourcing medical transcription can help healthcare professionals to deliver their best performance.
Portable digital recorders are go-to devices that providers use to record medical reports. These handy recording devices offer a fast, simple and convenient way to save recorded files onto them. Either in-house transcribers or healthcare providers have to sit down to transcribe the dictation later, which is a process that takes a massive amount of time away.
Medical records include everything a medical professional dictates, including notes for surgery, op notes, chart reviews, discharge summaries, and trips to the doctor’s office and emergency room. Medical records help doctors analyze a condition and draw inferences. Transcripts help pinpoint what occurred during a procedure and plan possible next steps.
For outsourcing, health professionals often upload and share these with a medical record transcription provider via encrypted email or secure HIPAA-compliant messaging apps. Outsourcing to specialized transcription companies can help healthcare providers to use their time better to focus on their patients.
Because medical records, clinical summaries, and doctor’s notes are so crucial, it’s compulsory that healthcare providers turn them into written text files to be readily read, saved, reviewed, and distributed to other healthcare professionals. These dictations in readable transcript format are often a deciding factor in the prompt diagnosis and treatment process, insurance claims, and reviewing patient medical histories.
These 5 Cs in medical record documentation are crucial to grasp for those who maintain patient records.
· Clarity: Proper grammar, correct spelling, use of accepted medical terminology, and standard abbreviations in the record are crucial to clearly document healthcare processes.
· Conciseness: An excellent medical record must contain concise notes and keep the report brief and to the point.
· Completeness: In the documentation, no data field should be left empty. One must fill all medical forms accurately, and the medical record must include all necessary information.
· Confidentiality: The confidentiality and security of all the data in the patient’s medical records are essential.
· Chronological Order: All entries must be date-stamped, and reports must follow a chronological sequence. When every detail is in chronological order, patient care documentation becomes very straightforward.
Many healthcare professionals find that in-house transcription of their medical records, reports, summaries, and notes takes a substantial amount of time each day. Or worse, to get the job done, they hire ridiculously expensive in-office medical assistants, only to find out that they also take too long to prepare the transcripts. Apart from being too expensive, this approach often produces inaccurate transcripts because these assistants are often severely undertrained and incapable of handling specialized medical transcribing needs.
In this situation, the best strategy is to use a medical transcription service provider. To transcribe medical records adequately, you can outsource all required transcription work to a reputed company like GoTranscript, where professional medical transcriptionists can produce and transcribe various medical documents accurately and faster.
Medical transcriptionists don’t just transform dictated audio files into a large block of text. They will edit and format reports precisely per your requirements and then securely return them via encrypted email or any safe digital messenger. So, to expedite your record-keeping process, assist more patients, and have thorough, more accurate medical records, it is wise to seek the assistance of a highly specialized transcription company today!