Medical transcription outsourcing: Paving the way for clinical documentation improvement

Time and again it has been proven that services like healthcare cannot function effectively without proper documentation. Given the enormous strides that information technology has taken, healthcare documentation draws a lot of support from IT to improve accessibility and convenience. The process of documenting the patient encounter/s in its entirety has been defined as clinical documentation. The ultimate goal of clinical documentation is the expression of the health status of a human being.

It essentially includes the process of arriving at the conclusions regarding the health status of the patient including:

• Evaluation of current symptoms
• The relationship of the patient’s current status to the previous health history, which includes:

1. Family history
2. Social history
3. Surgical diseases
4. Review of the patient’s body systems
5. Risk factors that affect the patient.

The clinical documentation process is not just restricted to the healthcare professional directly involved in the care process but also includes other participants like the nutritionists, physical therapists, psychologists and other healthcare specialties. Clinical documentation improvement helps in improving accuracy, convenience and accessibility to patient medical records.

This is achieved combining human intelligence and available technology to create, aggregate and transmit precise clinical data. Medical transcription plays an important role in this process by helping healthcare professionals document the care process in an accurate, timely, secure and cost effective manner. Given that medical transcription is a specialized skill that requires personnel with the right skills, advanced technological support and the use of stringent processes to achieve optimum results, outsourcing medical transcription has been found to be an effective solution.

How do outsourced medical transcription service providers pave the way for clinical documentation improvement?
The goals of clinical documentation improvement include:

• Allowing healthcare professionals to focus on their primary goal of providing quality care: Documenting the care process using medical transcription enables healthcare professionals to concentrate totally on their patients rather than the process of documenting. Not only this patient medical records created by medical transcription service providers reflect the narrative portion of the patient encounter, which provides healthcare professionals access to the complete patient history improving the diagnostic process.

• Ensuring that patients can rely of secure and accurate health records: The process of healthcare requires a delicate balance of trust between the care provider and the patient. Patients expect their medical histories to reflect accurate details and that this information would be kept confidential. Medical transcription aids in both these aspects.

• Ensuring the healthcare facilities can

1. Optimize care: Outsourcing medical transcription helps healthcare facilities curb direct and indirect costs of medical transcription helping them focus primarily on providing quality healthcare helping them optimize care

2. Lower risks: Complete documentation details the care process, which provides a valuable tool for risk management. Documenting the care process using medical transcription process ensures that the care process is documented accurately and on a timely basis, mitigating risks

3. Accelerate reimbursements: Outsourcing medical transcription ensures that proper documentation of the care process is done on a timely basis. Timely and proper documentation of the care process aids in quicker and better reimbursement.

Outsourcing medical transcription ensures quality documentation in an economic way, with minimal disruption of the healthcare facility workflow, which helps pave the way for clinical documentation improvement.

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 affordable and integrated 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.