Chapter 16 Medical Records

The Changing Role of Medical Transcription Cost conscious Rapidly changing economy Impact of new technology

The Changing Role of Medical Transcription Electronic medical records (EMR) May delegate much of MT’s responsibility to other medical personnel Facilitate documentation and tracking of patient care and outcomes Quick and easy access to accurate and readily usable information

The Changing Role of Medical Transcription Electronic medical records (EMR) All patient charts are scanned into EHR system Partial scanning of patient charts Do not scan any old information

The Changing Role of Medical Transcription Outsourcing Contracting with a service outside of clinic or hospital Task accomplished at lower cost, faster turnaround time Advantages of outsourcing Important considerations before outsourcing Rapidly eliminating need for traditional transcriptionist

The Changing Role of Medical Transcription Voice recognition software (VRS) Converts voice to text using computer Specialized programs capable of translating highly technical medical terminology Continuous speech technology

The Changing Role of Medical Transcription Medical transcriptionist as editor Quality assurance (QA) manager Risk management Editor or auditor Flagging procedures

The Changing Role of Medical Transcription Authentication Electronic signatures Alphanumeric computer key entries as identification Electronic writing device Biometric system Impact of Medicare and The Joint Commission on electronic signatures

Confidentiality and Legal Issues Differentiate between confidentiality and privileged information Health Insurance Portability and Accountability Act (HIPAA) Regulations

Confidentiality and Legal Issues Protocols Procedures your office has in place to ensure patient confidentiality Confidentiality agreement Documentation of compliance with HIPAA MT usually under jurisdiction of respondeat superior

Types of Medical Documents Documents part of patient’s permanent medical record Vital to continued patient care May be reviewed by Other providers Attorneys Insurance companies Court

Types of Medical Documents Medical report must be: Neat Accurate Complete

Types of Medical Documents Common transcribed reports: Chart notes and progress notes History and physical examination reports Radiology and imaging reports Operative reports Pathology reports

Types of Medical Documents Common transcribed reports: Consultations Discharge summaries Autopsy reports Correspondence

Turnaround Time and Productivity Hospital reports fall into four categories STAT reports: complete within 2 to 4 hours Current reports: complete within 24 hours or less Old reports or aged reports: complete within 48 to 72 hours or less TAT reports: when requesting copies of your medical record usual TAT is 7 to 10 business days

Medical Transcription as a Career Future of medical transcription is changing Most health care providers use digital or analog dictating equipment to transmit dictation to medical transcriptionists

Medical Transcription as a Career Medical transcription professionalism Display a professional manner and image Demonstrate initiative and responsibility Work as a member of the health care team Prioritize and perform multiple tasks Adapt to change Enhance skills through continuing education

Medical Transcription as a Career Medical transcription professionalism Qualified MT: minimum of 2 years experience performing medical transcription in variety of medical and surgical specialties Certified medical transcriptionist (CMT) Registered medical transcriptionists (RMT)