As a physician, you know that electronic medical records (EMRs) store a variety of reports, including history and physical exams, operative reports, discharge summaries, inpatient progress notes, consultations, and radiology reports. It’s crucial for your healthcare organization to focus on ensuring accurate, timely, and
The radiology report is the main and often only means of communication between referring physicians and radiologists. Traditional radiology reporting involved a trained radiologist dictating the findings of a radiologic study or procedure and its documentation by a radiology transcription service provider. These reports
HIPAA or Health Insurance Portability and Accountability Act of 1996 focuses on protecting Protected Health Information (PHI). This law established national standards on how covered entities, health care clearing houses, and business associates share and store PHI. HIPAA-compliant medical transcription ensures that sensitive patient
“If You Didn’t Write It On Your Patient Care Report, You Didn’t Do It.”
The patient care report (PCR) is an essential document that conveys prehospital patient and demographic data to the emergency department or other hospital-based healthcare provider. Even as paramedics respond to
Even in this the age of electronic health records and speech recognition systems, human medical transcriptionists (MTs) still have a significant role to play in the healthcare system. They convert the physician’s dictated report into text format and highlight discrepancies for correction. Though this may