Documentation of meetings and appointments between patients and health care professionals such as doctors is important to maintain patients records for referral, insurance and lawsuit purposes as well as to give the best care possible. Medical transcribing services assist busy doctors to create long-lasting, accurate records. Transcription services offer dictation, online and written services. Here are some terms to know about medical transcribing services.
Dictation – Dictation is the process of speaking aloud while a person transcribes and writes what is being said as a record.
Electronic Medical Records – Transcription services often provide electronic records of their work for the people who hire them. Electronic records should be easy to search, secure and organized.
HIPPA – HIPPA is the Health Insurance Portability and Accountability Act. This Act standardized the recording of health insurance information, health transcriptions, notes and more. If you are hiring medical transcription services check that they are HIPPA certified. HIPPA ensures that patient information is protected even if transcription is outsourced overseas.
Outsourcing – Outsourcing is the process of hiring transcribers from overseas for typing up records. Outsourcing can be a cost effective way to have telecommute transcription service provided online or over the phone.
SmartPhone Dictation – Smartphone dictation allows a doctor to speak through a secure transmission 3G network that is typed in texts and notes by the transcription service.
Electronic Signature – For transcriptions that are saved in an electronic database it is important to find a way for doctors to sign off of what has been written. An electronic signature shows that a doctor has read and approved the text.
Billing Rate – The billing rate explains how much a medical transcription service charges and can be determined by line, word count or letter character.
Medical transcribing is an old practice that has seen many new advancements in recent years. Originally, written notes from doctors and other medical staff were taken using dictation and re-written or typed for patient records. As technology has advanced so has the process of transcribing database information. Today, most hospitals and doctors' offices are moving to paperless systems. Medical transcripts are more often obtained using voice recognition software. The process of turning patient information into easily read information is important in the health care process.
Medical transcribing today reflects our technological age. Many transcription professionals work from home offices. They may obtain certifications online and are hired to telecommute. Records are usually stored electronically. Doctors and nurses use hand held equipment such as PDAs for reviewing patient records. They can also use these programs for typing notes directly into the system.
In the event that a hospital still uses written information, transcribing can be performed using traditional means. Notes from the doctor can be taken using dictation. Then, records are transferred to software and formatted to fit an electronic system. Health care providers may employ persons to perform this function on-site, however outsourcing is the most common means of acquiring this service.
Online access to records and recorded text have brought medical transcribing into the technological age. Accurate recording, the latest electronic equipment, and knowledge of current regulations regarding patient privacy are crucial components of this industry today. Accurate record keeping in whatever form, is an important part of ensuring patients get correct and proper care. Making sure that each member on a patient?s medical team is fully informed of their diagnosis and history is an important part of improving health for every person seen in a medical office or hospital.