The information concerning your physical problems (both current and past), lab and pathology results, tests, prescribed medications, and diagnoses are all recorded by the doctor during a visit and saved as an audio file. Medical transcriptionists preserve accuracy as they write down these audio files. They are now an essential component of your medical account because doctors, nurses, and other healthcare professionals can access them whenever they are required.
Medical record transcriptionists focus on the healthcare delivery system. However, transcribed medical records are crucial in helping to diagnose patients and provide them with high-quality care.
Role of Medical Transcription
The role of medical transcription is compiling a patient’s medical history, which lays the foundation for future patient appointments and serves as a focus for doctors. Additionally, it helps the doctors determine the patient’s current physical state, design an effective course of therapy, and conduct prompt aftercare measures. Accuracy is a very important factor because even small mistakes can have a big impact.
The need to maintain medical records is mandated by law, which is another major reason for accurate transcription. In the event of legal disputes, these documents prove to be of enormous importance.
Ways in Which Medical Transcription improves Patient Documentation
- Management of Delay in Documentation
Healthcare facilities run a busy schedule. Radiological reports, assessments, and surgical documents are examples of paperwork with a permissive response. However, some records must be completed right away, such as discharge instructions. Medical professionals are always overburdened with healthcare duties, patient documentation is a laborious procedure, and it requires correction sporadically when any mistake occurs. With their busy schedule and numerous responsibilities, patient documentation gets delayed which sometimes causes delays in treatment. Here a medical transcription service can be of great help.
Professionals who specialize in medical transcribing can accurately record all dictations and statements. They have the drive, perseverance, and focus necessary to accurately transcribe medical information. This enables doctors to treat their patients effectively and quickly.
A transcription service can help to quickly complete the transcription of the patient record. This is crucial when dealing with urgent paperwork like discharge reports that must be processed straight away. They can take care of the transcription deadlines so doctors can focus on core functions.
- A compulsory process by Law
Even though it is uncommon, there is always a risk that an ill patient, their family, or the family of a deceased patient will resort to legal routes when they suspect some mishap during treatment. Doctors and their practice are exposed to the risk associated with such an occurrence, Here patient documentation becomes a crucial matter of evidence.
Laws are enforced in the healthcare industry for maintaining and retaining records. The care given to a patient requires doctors to create comprehensive records about it. There are specific laws by which these patient records are to be maintained. For Instance, In the US, HIPPA (Health Insurance Portability and Accountability Act) defines the process by which patient records are to be maintained. Here Medical transcription proves to be quite beneficial.
- Error-free Patient records lead to better treatment plans
The necessary training and guidance are provided by the transcription professionals to the support staff. To administer the proper care and treatment when a doctor is not there, the nurses and assistants use patient documents as a reference.
Additionally, it is beneficial for them to watch out for any cautionary indicators or symptoms and to take their medications exactly as directed. So, it can be understood how patient records can be of utmost help in various scenarios.
Patient documentation may undergo changes when any additional procedure is performed as per the risk assessment. Medical transcription services will be able to properly document the changes and will be able to provide markers as per the wishes of doctors. When patient documentation is done with a professional transcription service, it proves to be helpful for a doctor to understand past records and devise a treatment plan.
These patient documents are even more useful because patients undergo treatment with different doctors/facilities for different treatments. Here doctors can easily identify the medicines/treatment plan a patient is following. A properly transcribed patient document proves to be an effective tool when it is done in an error-free and professional manner.
- Easy Verification of Insurance eligibility verification
A lot of individuals rely on insurance funds for their medical expenses. It is painful to see a patient forgo necessary care because of the high expense or because treatment is too expensive for them. The hospital billing staff can utilize the patient record they created after transcribing the data to submit it to the insurance companies for claim settlement. Making insurance eligibility verification a simple process.
Medical records of transcriptions facilitate quick insurance claim approval. Verifying medical data is a crucial step in the medical insurance claim settlement process. The most trustworthy papers or files to use for that purpose are transcriptions. In a dispute between patients and insurance companies during the process of paying claims, these can also be used as legal proof.
Patient documentation becomes better and provides the desired results when proper recording of data happens. A medical transcription service can be very effective for maintaining these data and additionally it provides medical professionals to focus more on their core function of treating patients and not draining their energy on paperwork.