The importance of documenting the patient encounter is manifold as it helps in many aspects that contribute to the smooth running of healthcare facilities, besides being a statutory necessity. As healthcare services are critical it is important that the process of documenting the patient- healthcare professional encounter be subject to certain norms. The patient – healthcare professional encounter can be documented by various means, one of the most preferred being medical transcription; a process which converts dictation to text.
As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.
Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.
Act: Making a policy for quality assurance
As quality in medical transcription is not only vital, but also a continuous process, it is important for medical transcription service providers to have a quality assurance policy based on the following guidelines:
- Apply the principles of quality while tailoring the quality assurance process specific to the organization
- Assess the specific factors that affect outcome of the documentation process including the workflow, turnaround time and technology while establishing a quality assurance policy
- Establish a budget specifically for implementing quality measures in the medical transcription process
- It is important to not only specify the quality process but also make it available to every person involved in the medical transcription process including the medical transcriptionists, proofreaders, editors, quality assurance team etc
- It is important to tweak the quality policy according to account specifications and update it constantly as per changing requirements
- Make quality an automatic step in the workflow following audio to text without adversely affecting accuracy or turnaround time. This can be based on the account and experience of the medical transcriptionists. Concurrent reviews are needed for inexperienced medical transcriptionists to improve quality and retrospective reviews provide valuable inputs for learning
- It is important to provide feedback on the results of the reviews to help improve performance of medical transcriptionists
- Train the assessment staff
- Establish and follow guidelines for the frequency of quality assessment
- Provide all inputs and resources to medical transcriptionists and other staff to ensure quality output
TransDyne, a leader in the medical transcription industry has made quality a key word in their work processes. TransDyne has adopted the process of continuous and comprehensive quality improvement to improve quality of medical transcription at every level. TransDyne realizes that quality is continuous process and therefore Quality Guidelines are established and implemented at every level. This attitude of adopting quality as the basis of their services and their aptitude in information technology has helped them come up with easy to use medical transcription solutions that help save on time, money and efforts.
TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!
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