In the U.S., federal and state laws require that every health care provider establish and maintain an accurate medical record for each patient. The HIMSS says that, “Regardless of format, whether paper, hybrid, or electronic, the medical record must meet the requirements of the legal and business record for the organization.” Accurate medical records can be generated by transcribing the physician’s dictation with the help of a reliable and experienced medical transcription service provider.
A medical record or a medical document is the most crucial element of a healthcare organization and an important part of the process of diagnosis and treatment of patients. Patients’ medical records are kept in a secure place, so that they are safe from unwanted access and can be accessed by authorized personnel only. With the advent of digital technology, storing information is easier than ever before. Information can be stored on computers, hard drives or servers. Today, hospitals, clinics and other healthcare practices use electronic health records (EHR) for storing patient information, which enables doctors to access the necessary information quickly and easily.
Medical Records and Their Legal Use
Accurate medical records not only help in ensuring good patient care but also serve as legal documents for healthcare providers as they contain information about adverse events such as accidents, criminal activities and any such act that harmed patients and for which they are under treatment. These medical records may be referred to in legal proceedings to understand the diagnosis, treatment, and progress of a patient, or they may be used to prove malpractice on the part of a health care provider. The medical record is a reflection of what occurred between a patient and his or her provider as far as the medical care that was provided. It has important evidential value. In case of any malpractice, legal experts regularly refer to the medical records to determine the quality of care that was provided and whether or not the accepted standards were followed. The medical record is also critical for patients who are involved in litigation as it provides a clear and detailed account of what happened during the treatment. In short, the medical record is an essential part of any healthcare provider’s practice.
Electronic Health Records May Be Error-prone
When physicians prefer to dictate their treatment notes, consult notes, progress notes and so on, these have to be accurately transcribed and details entered into the electronic health record system. Given the medical record’s value as a legal document, accuracy is paramount. The toughest part of medico legal transcription, whether done in-house or whether outsourced, is transcribing unfamiliar medical terminology that is an integral part of medical records. Therefore, it is important to reach out to an experienced, professional medical transcription company that can deliver international standard medico legal transcription with the highest accuracy and quality.
Not all EHR systems may have automated transcription feature that is legally valid. Another point to remember is that automated medical transcripts may have issues such as missed diagnosis, wrong lab results, patient mix-up, juxtaposition errors, template errors and so on. However, a medical transcription company providing EHR-integrated medical transcription will help physicians, practices, and healthcare facilities meet all the medical-legal requirements for their electronic health record system. They will stay HIPAA-compliant and help avoid legal risks.
Electronic health records that are not properly designed and used can cause inadvertent errors such as dosing errors, loss of data, failure to diagnose serious illnesses, treatment delays and so on. With a good EHR-integrated medical transcription service, each and every record is checked and clarified to ensure they are error-free. This helps avoid claim delays and denials as well as costly litigation.
These services provide benefits such as the following.
- Comprehensive and accurate medical documentation that helps ensure patient safety and HIPAA compliance.
- Privacy: Professional medical transcription providers ensure the privacy of sensitive medical information. Transcriptionists are trained to protect private information both on the clock and off, and avoid any discussion of protected documents.
- Speed: In the age of electronic health records, hospitals are employing medical transcriptionists to update patient records quickly, providing many exam and test results within hours after they have been performed.
- Terminology: Professional medical transcriptionists are familiar with complex medical terminologies and ensure accurate and error-free medical records.
Medical records are valuable documents because they are related to human life; they have legal and business requirements to meet and are expected to adhere to prescribed standards that assist the professional, regulatory, and statutory needs of reliable medical-legal documents connected with healthcare organizations. Therefore, to minimize in-house workload and stay legally compliant, healthcare entities can utilize EHR-integrated medical transcription services. This ensures that the medical records are reliable and valid, which in turn ensures patient safety. EHR-integration solutions are available for all types of electronic interfaces including Document interface and ADT interface.
