Medical transcription outsourcing: Helps create legally compliant documents

While documenting the patient- healthcare professional encounter has an impact on the process of providing care and for coding purposes, another important aspect of documenting the patient encounter is that of meeting compliance standards so as to provide valuable support for risk management. Healthcare facilities have various options available to them for documenting the patient- healthcare professional encounter, more so now due to the changes in the documentation scenario. Each option available for documenting the process has its own pros and cons.

However keeping in mind the valuable role played by patient medical records in the smooth running of healthcare facilities it is important to pick a method of documentation that is preferred, convenient, easy to use and most importantly helps document the patient encounter in a manner that supports the legal and compliance aspects. It has been found that medical transcription services meet all these criteria. As medical transcription is a specialized service requiring a combination of the right team, the right technology and the right process to meet all these criteria, outsourcing medical transcription to a professional medical transcription service provider has been found to be an effective solution.

How do outsourced medical transcription services help create legally compliant patient medical records?

To meet legal requirements a medical transcript by definition must meet all statutory, regulatory and professional requirements for clinical purposes as well as for business purposes. Patient medical records should meet the norms like:

• A unique medical record should be created and maintained for each patient.
• The medical record should include author of the record, date of the encounter, time of treatment, and authentication as appropriate
• It should be accessible and also meet all security and confidentiality norms
• It should be created according to the procedure required for forms, template etc for specific reports
• The retention, archiving, destruction (of defunct) records should have appropriate procedure to enable data quality management.

Outsourced medical transcription services help in all these aspects of quality data management by providing services with the following benefits:

• The patient- healthcare professional encounter is transcribed in its entirety to include all the details as required.
• The identifying information provided by the healthcare professional is recorded carefully along with the detailed record of the diagnostic and treatment procedure.
• Outsourced medical transcription services ensure that the patient medical records are made easily accessible by delivering the transcripts through the modes specified by the healthcare professional, using HIPAA and HITECH compliant channels
• Outsourced medical transcription services create transcripts as per the specific template/ format required for the specialty and as specified by the healthcare professional.
• Outsourced medical transcription services provide a system for archiving transcripts that allows for easy access. Older transcripts are archived as per the specific requirement of the healthcare professional/ healthcare facility to enable easy data management.

It can be seen that outsourcing medical transcription enables proper and descriptive documentation of the patient story retaining the narrative while still enabling adoption of EMR/EHR using HL7 interface.

TransDyne, a leader in the outsourced medical transcription industry has used their extensive background in information technology and their experience in serving the needs of the healthcare sector to provide total medical transcription solutions.

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!   

To avail complete medical transcription services from TransDyne, click here.