Error is prescribing the right treatment, would not just risk the practitioner’s career, but also lead to fatal repercussion for the patients.
The various steps that are involved in the medical transcription process are –
Patient – Doctor Interaction –
The physician would question the patient, examine the lab reports and make a diagnosis. Then the course of treatment would be decided and prescribed
Recording or Dictation –
After the consultation, the practitioner would dictate the patient notes and treatment details discussed, into a recorder or on a telephone call.
Many medical transcription organizations offer answering and medical transcription services. As part of the answering service, the clinic or individual practitioner is given a toll-free number where they would call and dictate the information. This information is stored on the company’s secure server
If the information is recorded on to a digital recorder, the recording is sent to their account with the transcription service provider through a secure server or file transfer protocol.
Dictation retrieval –
The recording is downloaded from the company’s server, allocated a unique job ID and assigned to qualified medical transcriptionist. The transcriptionists are knowledgeable of medical language and healthcare jargon that would help then interpret, transcribe and edit the dictation about the prognosis and diagnosis of illness, therapeutic methodologies etc.
Medical transcriptionist use headphones, word processing software, media player etc to hear the dictation and type it out as text. These editors rewind and replay the recording several times to ensure that they weren’t making a mistake or missing any crucial information. The recordings might sometimes unclear due to the recorder used or even the language usage and accent of the physician. In such instances, information from American Drug Index, American medical Association etc is used as references to verify the information in the dictation.
As information is transcribed, it is constantly updated to the secure server, making it available for the physicians to review and make changes if required.
Quality assurance –
The transcribed information is proofread and edited including medical editing. During this step the spelling and grammar, medical terminologies, formatting and dates are relooked.
Every effort is taken to ensure complete accuracy in the answering and medical transcription services provided.
Transfer of Completed Transcription –
The completed transcription is sent to the physician server through a secure server using FTP for the physician to access and retrieve the completed records whenever needed.