Medical transcription: Quality Guidelines to improve the quality of documentation

The importance of documenting the patient encounter is manifold as it helps in many aspects that contribute to the smooth running of healthcare facilities, besides being a statutory necessity. As healthcare services are critical it is important that the process of documenting the patient- healthcare professional encounter be subject to certain norms. The patient – healthcare professional encounter can be documented by various means, one of the most preferred being medical transcription; a process which converts dictation to text.

As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.

Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.

Check: Providing guidelines for quality assessment

Quality Guidelines are an essential tool for assessment of quality in medical transcription. It is important for healthcare facilities to assess the quality policy of the medical transcription service providers by determining the method of quality assurance and Quality Guidelines.

The Quality Guidelines for medical transcription have been categorized into two main categories:

Critical errors: Errors under this category have been a assigned a value of (-3)

The errors, which are considered critical errors, have been defined as those errors, which can have serious consequences due to their occurrence. These include:

• Terminology misuse: An incorrect word can lead to a potentially dangerous situation resulting in the wrong diagnosis, the wrong medical decision and wrong billing. Implication of this error can permeate several levels.

• Omission/ insertion: Omission of key words or insertion of the wrong word can adversely affect patient safety.

• Incorrect patient demographics/ wrong author identification: This category could include the wrong identification of the patient, the wrong serial number, wrong medical record number, wrong date of encounter etc which could have long reaching implications

Non-critical errors: Errors under this category have been assigned a value of (-1)

Errors under this category have an overall impact on the accuracy and integrity of the document, but do not affect patient safety. These include:

• Misspelling: This means the wrong spelling of words that compromise the integrity of the document

• Incorrect verbiage: This refers to errors caused by inappropriate or excessive editing which do not have significant impact on the meaning of the document

• Failure to flag: This refers to the failure of the medical transcriptionist to flag reports that need clarification

• Protocol failure: This refers to not following protocol like failing to mark courtesy copy etc.

• Formatting / account specification: This refers to the failure of the medical transcriptionist to follow the formatting or account specification

There are other errors, which have been categorized as providing feedback or educational opportunities, these include:

• Grammar
• Punctuation
• Capitalization
• Plurals
• Run on/ fragmented sentences
• Abbreviations
• Slang & inflammatory remarks
• Abbreviations
• Inconsequential typos and omissions
• Capitalization of drug names
• Incorrect word forms

TransDyne, a leader in outsourced medical transcription industry has made quality a keyword in all their processes, including the process for training. Medical transcriptionists are impressed upon regarding the importance of quality and care is taken to provide the medical transcription team with the right support and resources to enable quality medical transcription.

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