The major challenge gastroenterologists have to face is the lack of time for opportune and accurate patient documentation. Gastroenterology transcription service can help physicians manage the documentation challenge and benefit from improved patient documentation.

1. Gastroenterology Specialty
Transcription - Challenges,
Technology and Use of a Specialist

2. Gastroenterology is a medical specialty concerned with the digestive system and its
disorders. The major challenge gastroenterologists have to face is the lack of time
for opportune and accurate patient documentation. Wasting time on documentation
can limit the time for patient consultation and diagnosis, which can inversely affect
patient care and satisfaction. Apart from this, incomplete or inaccurate
documentation can also result in claim denials or delays.
Documentation Challenges
Let us take for example a patient presenting with symptoms of belching. You will
have to diagnose whether it is a gastric belch (normal physiologic activity) or a
supragastric belch, which is typically a behavioral problem. You will have to review
and document the patient history that would reveal the patient’s behavior pattern
while sleeping and when distracted. Since supragastric belching is typically a
behavioral problem, the belching should stop when sleeping or distracted. Once the
diagnosis is made, you have to document that accurately.
Then comes the condition management part - Since belching tends to be worsened
by stress, you will have to identify other behavioral components or psychological
components that need to be considered. Neurocognitive symptoms that reveal
underlying psychiatric disturbances can be managed with pharmacologic agents. In
such cases, you have to refer the patient to a psychiatrist for counseling,
neuropsychiatric evaluation or cognitive-behavioral therapy. There may be cases
when the intervention of a speech pathologist may also be necessary. Sometimes
hypnotherapy may prove to be useful.
All the above details have to be clearly recorded to ensure appropriate patient care
and follow-up support. Many gastroenterologists would agree that it is easier to
dictate patient data than enter it into an electronic record system.
Clinical components of a medical examination include information such as the
following, which have to be accurately documented.
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Vital signs such as the patient’s temperature, pulse, respiratory rate and
blood pressure
Chief complaint
Progress notes that show the care provided, and medical facts and inferences
relevant to diagnosis and treatment
Patient’s past medical history
Family and social history
Allergies
Medication list
History of present illness
Review of systems (ROS)
Diagnosis and assessment
Plan and treatment
Whether in a traditional paper-based office or an advanced medical office with an
EHR system in place, providers will have to document patient encounters. EHRs allow
physicians to enter data by typing in free text, responding to templates that contain
commonly used clinical terms, and symptoms, or by using voice recognition
software. For a busy gastroenterologist, finding the time for documentation is a
major challenge. This may ultimately result in cutting down the number of patients,

3. which is bound to have an impact on the practice revenue and also lead to patient
dissatisfaction.
Is Speech Recognition Software a Reliable Solution?
According to a research report, use of voice recognition in radiology practices has
increased the number of error reports quite significantly. This can happen in a
gastroenterology practice as well. This usually happens in noisy places with a high
workload and the reports are prepared by providers whose first language is not
English. The software is not good at recognizing voices with heavy accents and
cannot deal with disorganized dictation, poor grammar, and missing or overused
punctuation. Increased cost for implementation is another factor that makes human
transcription superior over voice recognition technology.
Even with a speech recognition system that is claimed to be reliable, human editing
of the transcripts is necessary. Medical transcription companies in the present era
offer the service of their medical transcriptionists who are medical language
specialists (MLSs) for physicians looking to streamline their workflow.
How a Medical Transcription Company Can Help Meet the
Challenge
Assigning the task of medical documentation to a medical transcription company
will be helpful for gastroenterologists to have quality documentation services, within
specified time limits. Their team of experienced professionals provides specialtyspecific transcription services, in this case, gastroenterology.
Professionals handling gastroenterology transcription will be well versed in
medical terminology, conditions and procedures specific to gastroenterology. You can
continue dictating as you are used to and the medical transcription company will
provide transcripts of reports such as the following.
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Biopsy of liver reports
Colonoscopic reports
Consultation notes
Endoscopic examination reports
History and physical examinations
Laboratory test reports
Nasogastric and intestinal tube reports
Sigmoidoscopy reports
EMR/EHR Transcription Service
This is the era of electronic health records and therefore reliable medical
transcription companies have risen to the occasion, providing efficient EHR/EMR
transcription service. They offer different EMR and EHR transcription interface
solutions to ensure a smooth transcription process and outstanding quality.

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Transfer via network: the transcribed reports are delivered directly into the
relevant folders in the provider’s network based on the provider’s scheduling
preferences.
HL7 interface system: patient information is easily and efficiently captured
from the provider’s HIS/CIS/RIS systems and the transcribed reports are
returned to these systems within the required turnaround time.
Direct connection tool: using a VPN or other direct connection tools, real-time
transcription is provided into the provider’s system.
Gastroenterology Transcription Outsourcing Benefits
Cost-effectiveness is one of the major advantages of outsourcing medical
transcription. The services are provided at affordable cost, and gastroenterologists
can save 30-40% of the overall cost.
Confidentiality and security of gastroenterology medical reports are important for
ensuring privacy of patient information. Service providers conscious of HIPAA
compliance ensure utmost security and confidentiality for your medical documents.
Moreover, doctors can rely on convenient dictation option such as digital recorders
and toll-free numbers, for accessing their service.
Accuracy: - Quality services are ensured by skilled professionals, with adequate
knowledge in gastroenterology terms and procedures.
Timeliness: - Professional transcription companies follow strict time schedules and
produce the transcribed reports in quick turnaround time.
Efficiency: - As the team of medical transcriptionists is specialized with
terminologies and procedures in gastroenterology, they can deliver efficient services,
both in terms of quality and quantity.
There is no doubt that reliable gastroenterology transcription including EMR/EHR
transcription service will help gastroenterologists benefit from improved patient
documentation. Though the electronic health record system is quickly changing the
working pattern in medical practices, patients are still being seen, medical charts are
being created and medical transcriptionists or medical language specialists still have
an important role to play when it comes to documentation and quality assurance of
the medical records. Medical transcriptionists are also indispensable in practices
using voice recognition software. There they can take up the role of editors, clinical
data specialists, data quality managers, and decision support specialists to ensure
error-free medical records.
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