Given the increasing demand for quality healthcare services, there has been increase in the demand for all the components of quality healthcare. As the volume of people seeking healthcare services increase the need for quality documentation also increases, as it is a vital component that helps deliver quality healthcare consistently. Clinical documentation is the process of recording and communicating a written record of the patient- healthcare professional encounter consisting of assessment, inputs from other experts if needed, the diagnosis, the treatment plan, treatment provided, the progress of the patient's response to treatment, discharge and discharge instructions. The criteria for high quality clinical documentation are legibility, completeness, clarity, consistency, precision, reliability and timeliness.
To meet all these criteria and to be efficient, clinical documentation depends on narrative dictation, which then can be transcribed to be a part of the patient medical record. The process of converting the audio of the healthcare professionals' narration into text format is known as medical transcription.
In the recent past the Medical Transcription Industry Association has changed their name to Clinical documentation Industry Association. The reason behind this is to redefine the role of medical transcription in the changing healthcare documentation scenario by providing innovative solutions for EHR adoption and helping the timely and accurate capture of health information.
Considering the redefinition of medical transcription services and medical transcriptionists as clinical documentation specialists rather than mere typing services it is important to look at the changing role of medical transcription in the current scenario.
What is the changing role of medical transcription services in the current scenario?
Helping retain the narrative as part of patient medical record:
- Helping retain the familiar dictation- transcription: Medical transcription can help healthcare professionals in the process of adopting EHR systems while still retaining the familiar method of dictation to medical transcription. This helps the narrative become part of the patient medical record providing a valuable diagnostic tool that aids in clinical decision making
- Transitioning from transcribing to editing: In those instances where healthcare professionals are using speech recognition software to produce patient medical records, medical transcription services have evolved into editing and proofreading services that help in improving the quality of documentation
Helping retain the integrity of information: Though other methods of documentation like point and click entry or speech recognition software can help improve the turnaround time, the integrity of the information captured may be compromised. Medical transcription services help in this aspect by checking the integrity of the data and improving the accuracy tremendously.
Helping improve the productivity of healthcare professionals' time: Documenting the patient- healthcare professional encounter using the dictation to medical transcription method helps increase the productivity of the healthcare professional and helps increase focus on the process of providing quality healthcare.
It can be seen that medical transcription services have evolved to become an important component of the healthcare documentation scenario, by providing medical transcription services that are accurate, flexible, convenient, timely, secure and cost effective using a combination of well trained medical transcriptionists, the right processes and the right technology.
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