• Sep 23

    Versio Staff

    Say What? Just Type What the Doctor Says?

    by  Versio Staff


    Noun; /tran-skrip’shun-ist/: A quick-fingered specialist who can decipher a dictator speaking at warp speed on a cell phone while eating chips in a heavily populated office that is being vacuumed.

    Levity aside, we all know it is very important to maintain an accurate patient medical record. Quality documentation is vital to ensuring patients are receiving the best care possible. The medical transcriptionist (MT) plays an important role in this endeavor. It is the MT's responsibility to honor the physician's dictation style while also recognizing when to edit and when to flag errors and inconsistencies within a report.

    A MT is responsible for producing a report with correct grammar, punctuation, and spelling. This is common practice, and technology is certainly helpful managing this aspect of the report. However, a MT also has to be fully engaged in the report content and use crucial critical thinking skills to catch some of the less obvious errors and inconsistencies. This is something that requires a human element and cannot be replaced by technology such as voice recognition (VR) alone. In fact, a best practice is to have a MT edit any reports generated by VR to ensure they accurately reflect the meaning of the physician’s dictation.

    A MT has a responsibility to edit or flag reports for contradictory information, contextual inconsistencies, and transposition of terms and values. For example, a report is dictated that describes the situation for a female patient, including a female exam, but the dictator dictates the pronoun "he" in the assessment. Using critical thinking skills, it is obvious the patient is a female and the MT can safely edit this pronoun to "she."

    However, just as important as catching errors and inconsistencies is the ability to recognize situations where it is inappropriate for the MT to alter the dictated report. A MT has a responsibility to flag any instances that further require the dictator's attention. For example, a report describes a child with a broken leg, but the dictator refers to the left leg and right leg throughout the report. In this situation, it is not entirely clear what is intended and an MT should flag this report for the dictator to review.

    There are many anecdotes of “bloopers” in dictated reports. What if some of these examples made it in to a report that was distributed to the care team?

    • “Patient left his white blood cells at another hospital.”
    • “Patient had a left toe amputation 1 month ago. He also had a left foot amputation last year”
    • “Duration of illness is probably at least since he became ill.”

    Great medical transcription involves more than just having MTs type what is dictated. It requires terrific MTs with excellent attention and critical thinking skills. It also requires a top-notch quality assurance department to assess flagged reports and communicate questions and issues to the dictator. This is where Versio really shines!

    With the move from “physician-owned” records to a shared record environment, quality documentation has become even more critical, as every error has high visibility and creates ripple effects. Versio has been in the clinical documentation business since 2000, and we are passionate about accurately capturing the patient story. Our US-based staff delivers hundreds of reports every week and our clients love us!

    For more information on Versio’s transcription services, go to www.MyVersio.com or email sales@myversio.com.

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    Posted in Industry Information