Medical Transcription Alabama | Not just Verbatim – Relevant & Meaningful Transcripts are Significant
Fundamentals of Medical Transcription
The practice of Physicians and all types of medical practices normally keeping details of their patients in the form of medical records has been in existence since long. The diagnosis, treatment, and overall health management processes performed by the physician are dictated in audio format and this is recorded in text format for future reference. While the medical professional dictates the report in any convenient form, the transcriptionist takes up responsibility of storing the medical information in an error-free manner.
Importance of Quality Medical Transcripts
- Medical Transcription forms the basis of the reference record about a patient’s complete medical history that helps clinicians to manage their health
- Patients may need t be treated by different physicians. Detailed health records enable physicians to manage the patient’s health using the medical information that has been recorded in the form of transcripts
- Nurses and other paramedics will be able to perform better, if patient records are presented in easy to follow and relevant manner
- Billing & Coding staff may use accurate medical transcription for claims and reimbursement purposes
Verbatim Transcription Service
Making use of exactly the same words that were originally used by the medical professional is what is basically expected in transcripts. The very objective of the patient health record is providing a comprehensive and transparent picture of past and the present patient history, contraindications, and treatment, in addition to future plans for treatment. Having to achieve these crucial needs, if each and every word as used by the author, were used, the purpose may not be solved.
Relevance is Vital in Medical Transcripts
In the venture of assisting medical professionals to better-manage the health of patients, transcriptionists play a vital role. They need to be trained and skilled in not only following the dictation of physicians perfectly but also rendering the transcripts meaningful and supportive. Certain comments and noises, exclamations and insignificant remarks need to be filtered. The transcriptionist has to be an expert in language, medical terminology, and relevant processes involved in the particular medical condition or disorder that is being managed.
General Guidelines for creating effective transcripts
Transcriptionists must follow certain steps in order to come up with the most effective and useful transcripts that help practices and physicians. A few have been listed below:
- Following author’s dictation pattern so long as it produces clear meaning
- Correcting and editing minor punctuation and grammar errors
- Flagging questionable or contradictory information
- Expanding abbreviations to deliver clarity
- Transcribing headings and titles as dictated
- Removing redundant data
- Flagging things that require major edits
The very purpose of medical transcription is to deliver easy to follow health records, hence, the transcript must be precise and explanatory. Transcripts must not dilute the integrity of the basic record and its author’s intentions. The balance between maintaining the record’s integrity and author’s style is what the expert transcriptionist is expected to achieve.
Numinatrans has been in medical transcription field since last 16 years. We are pioneers of transcription process in India.
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