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The Changing Role of Medical Transcription in the Digital Era

Explore the impact of technology, outsourcing, voice recognition software, MTs as editors/auditors, confidentiality and legal issues, types of medical documents, turnaround time, and professionalism in the field of medical transcription.

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The Changing Role of Medical Transcription in the Digital Era

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Presentation Transcript

  1. Chapter 16 Medical Records

  2. The Changing Role of MedicalTranscription • Cost-conscious and rapidly changing economy • Impact of technology

  3. Electronic Medical Records • Difference in who enters information into the EMR • Advantages of EMRs

  4. Outsourcing • What is outsourcing? • Advantages of outsourcing • Important considerations before outsourcing transcription

  5. Voice Recognition Software • Converts voice to text using a computer • Specialized programs are capable of translating highly technical medical terminology • Continuous speech technology

  6. MTs as Editor or Auditor • Changing role of MT • Quality assurance • Risk management • Editor or auditor • Flagging procedures

  7. MTs as Editor or Auditor • Authentication • Electronic signatures • Alphanumeric computer key entries as identification • Electronic writing device • Biometric system • Impact of Medicare and The Joint Commission on electronic signatures

  8. Confidentiality and Legal Issues • Differentiate between confidentiality and privileged information

  9. Health Insurance Portability and Accountability Act Regulations • Impact of HIPAA on medical transcription

  10. Protocols • Definition: procedure your office has in place to ensure patient confidentiality • Confidentiality agreement • Documentation of compliance with HIPAA

  11. Types of Medical Documents • Documents are 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 • Report must be • Neat • Accurate • Complete

  13. Common Transcribed Medical Documents • Chart notes and progress notes • History and physical examination reports • Radiology and imaging reports • Operative reports • Pathology reports

  14. Common Transcribed Medical Documents • Consultations • Discharge summaries • Autopsy reports • Correspondence

  15. Turnaround Time and Productivity • Hospital reports fall into three categories • STAT reports – complete within 12 hours or less • Current reports – complete within 24 hours or less • Old reports or aged reports – complete within 72 hours or less

  16. Medical Transcription as a Career • The future of medical transcription is changing

  17. Professionalism Relatedto Medical Transcription • How to maintain a professional attitude • 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 CE

  18. Professionalism • Qualified MT is one with a minimum of two years experience with a variety of medical and surgical specialty documents • Certified Medical Transcriptionist (CMT)

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