Medical transcription outsourcing: Helping create cohesive patient medical records

It is a known fact that the healthcare process is information intensive and information dependent. The healthcare process depends on information to be able to deliver quality services, meet statutory norms, maintain profitability and to manage risks. The source of the information used for all these purposes originates primarily from the patient- healthcare professional encounter. This information is collected before, during and after the care process in the form of demographic data, complaints, symptoms, existing conditions, current medication, test results, lab results, procedures, insurance information etc.

To be used for various purposes it is important for this information to be available in the form of a cohesive record. Medical transcription, the process of converting the dictation of the patient- healthcare professional encounter helps create cohesive patient medical records. As medical transcription is a specialized process requiring intense focus, capital and various inputs to be effective, outsourcing medical transcription has been found to an effective solution. Outsourced medical transcription service providers help in the creation of cohesive patient medical records while still meeting the quality criteria of accuracy, turnaround time, security and lower prices.

How do medical transcription services help create cohesive patient medical records?

Cohesive patient medical records can be defined as records that are a culmination of all the relevant information regarding the patient record containing details like:

• Patient History and physical examination report: This contains a brief about the patient name, age, gender, occupation, family health history, habits like smoking etc. and the details of the physical examination.

• Consultation report: This contains the details of the findings by the consultant to whom the patient has been referred to for further treatment or diagnosis depending on the symptoms

• Operative report: This contains the details of the operation/surgery that a patient has undergone including details of the procedure, duration, the anesthesia given etc. This may also contains some postoperative details.

• Radiology report: This contains details of the radiologists’ findings on the X-rays, MRI scan, Ct scan, nuclear medicine, fluoroscopic studies etc along with the reports.

• Pathology report: This contains the findings of a pathologist of the tissue sample.

• Laboratory report: This contains the laboratory findings on body fluids

• Emergency report: This is a summary of the patient’s visit to the emergency room for emergency care.

• SOAP note report: This contains

1. Subjective: This section contains patient’s current condition like age, gender, and pertinent symptoms etc.
2. Objective: This section contains vital signs, findings from physical exams. Lab test results, co morbidity etc.
3. Assessment: This contains quick summary of symptoms and diagnosis etc.
4. Plan: This contains treatment plans, document goals for the patient with reasonable time lines etc.

• Progress note report: This contains progress of the patient after treatment/ operation/ procedure etc.
• Therapy report: This contains details of the therapy given to the patient
• Discharge summary: This contains all the details, which are generated when the patient is discharged including the treatment given, the progress of the patient, any reports and findings etc.

Outsourced medical transcription service providers help in creating a cohesive patient medical record by using a combination of skilled & specialty trained medical transcriptionists to ensure accuracy and turnaround time and use the right technology to ensure easy access and security. As medical transcription is the core business of the medical transcription service provider it results in economies of scale. Combining this with the experience and expertise of the medical transcription service provider results in substantial cost savings for the healthcare facilities.

Apart from the price, security and quality advantage, outsourced medical transcription service providers also provide the additional benefit of being able to adopt EMR/ EHRs using HL7 interface, while still retaining the familiar dictation-to- transcription method of documenting the care process.

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time and 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 expert medical transcription services from TransDyne’s click here.