1. Chapter 16
Medical Records

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

3. 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

4. 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

5. 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

6. 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

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

8. 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

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

10. 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

11. 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

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

13. 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

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

15. 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

16. 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

17. 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

18. 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)