Choosing a reliable and established medical transcription company for outsourcing transcription tasks reduces the chances of data errors and ensures precise documentation.
2. Electronic health record systems and the use of voice dictation
software are changing the face of medical transcription. Regardless
of these changes, accuracy and timeliness in documentation is
crucial to ensuring the quality of care and adherence to statutory
regulations. When a physician dictates and the medical
transcriptionist converts the audio file into a text document, there is
always the chance that errors will occur. Errors in medical
transcription endanger patient safety and the integrity of
documentation. Inadvertent mistakes have even had fatal
consequences.
Reasons why Medical Transcription Errors occur
Inexperience with medical terminology
It is important that the transcriptionist has in-depth knowledge about medical
terms, jargon and abbreviations. Physicians often use short forms for making
patient notes and expect the transcriptionist to know what these stand for and to
note them correctly when typing out a detailed transcript. As medical field is
advancing with new treatments and processes, it is essential for a transcriptionist
to stay updated with the latest medical terminology to ensure precise
documentation.
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3. Failure to understand the voice recording
There may be physicians with heavy accents as well as those who do speak
clearly or too fast into the digital recorder. Heavy background noises can
overpower the doctor’s voice in the recording and affect audibility, which in
turn can cause errors in the typed record. The transcriptionist must also be
able to make out heavily accented speech.
Spelling errors
This may occur with both equipment and medication names. Wrong
capitalizations, same sounding words, or word hyphenations are part of
spelling errors. Transcriptionists would need to research online or refer to a
medical compendium when they are not sure about something.
Failure to make a good judgment
The job of a medical transcriptionist also involves arranging important
documents so that healthcare professionals can refer to them while treating
patient. Their job also involves flagging a medical report, correcting
information, and doing comprehensive research to fill in the blanks. If, by any
chance, transcriptionists are not able to understand a specific medical term or
phrase, they should not try to guess the same as this can result in error and
cause serious harm to the patient and the reputation of the health care
provider.
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4. Inadequate proofreading of dictated reports
Proofreading and quality assurance checks are essential to ensure accurate
transcripts. Quality assessment is very important to ensure if the report has
been correctly transcribed. In leading medical transcription companies, multi-
level quality checks are conducted before the final transcript is submitted. This
ensures that healthcare documentation is accurate, complete and clear.
Dosage errors
Transcription errors are considered to be “critical” when they can have serious or
life threatening consequences which may impact patient safety. For instance, in
one case, Sharron Juno, a female diabetic patient died because of a typo. The
doctor dictated that the patient was to be given 8 units of insulin, but the
transcriber wrote it as “80 units” instead. The patient was given 10 times the
dosage as the doctor had specified and she died. The outcome of the transcriber’s
mistake was irrevocable.
There is a view that implementation of a computerized physician order entry
system (CPOE) and electronic documentation can reduce the chances of
transcription based errors. However, experience shows that errors can only be
avoided by cross-checking data and attention to detail.
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5. How to Avoid Transcription Errors
Physicians can ensure error-free documentation in the following
ways:
Select top quality digital recording equipment that offers the best sound
quality and clarity
Employ the services of a professional medical transcription company
Make sure that medical transcription service has proofreading and quality
assurance checks in place to detect and correct errors at an early stage
Ensure that the service provider has a well-trained and qualified team of
medical transcriptionists who are well versed in medical terminology and
jargon and have language skills.
With new healthcare laws, implementation of electronic health records, and
transition to ICD-10, physicians are busier than ever. Partnering with the right
medical transcription company is crucial to ensure error-free and timely
documentation for higher levels of productivity and efficiency.