Healthcare reform and advancements in health IT have transformed clinical practices and processes. With electronic health records, it has become even more critical to ensure high quality reporting and healthcare documentation to enhance care, assure patient safety and take care of the business aspects of the healthcare provider. The Association for Healthcare Documentation Integrity (AHDI) explains the role of both MTs (medical transcriptionists) and (MTSOs) medical transcription service organizations in its document on best practices for healthcare documentation:
Role of MTs:
- Request for review if there are any blanks or doubtful areas of dictation
- Review the available records or documents to resolve the discrepancies if any within the specific report
- Amend the dictation speed to optimize the clarity level
- Make use of reference materials such as online reference sites which are approved
- Go for suitable procedures to take the problems if any to the correct level
- Apply the updated feedback for improving quality continually
Role of MTSOs
- Execute procedures to identify and report problems and divergences to Health Information Management (HIM) staff
- Timely reporting of faulty equipment to HIM staff or provider who ever it is concerned
- Give proper feedback to HIM concerning dictation best practices which are beneficial. Training may also be provided for all of the authors, especially for fresher residents
- Keep a comprehensive and up-to-date list of templates and macros for the provider. Also share it out to transcription and editing staff, and notify them if any missing macros and templates are noticed
- Properly coordination with HIM staff to acquire precise and timely ADT feeds
- Offer continuous education and support for MTs on errors, questions, and blanks
- Allow MTs to make use of a comprehensive range of reference materials and resources to lessen the blanks if any
Established medical transcription companies adhere to such best practices and provide customized medical transcription services for their valuable clients.
