Quality is of utmost importance in medical transcription. Good quality dictation is necessary to ensure high quality medical transcripts.

1. TIPS
TO
MINIMIZE
DICTATION
ERRORS

2. Quality is of utmost importance in medical transcription. Effective documentation
of patient records depends greatly on dictation quality. Finding errors during a
physician dictation is not uncommon, whether it is human error (caused by
entering incorrect patient medical record number or date of service), low quality
audio from heavy background noises, or recording equipment malfunction. No
matter how qualified or experienced the physicians are or how many medical
miracles they perform, dictation errors are likely to happen.
It is not practical to expect that dictation errors can be completely eliminated.
There are different variables involved of which human error is one of the most
important factors. Speech recognition software cannot produce 100% accurate
and precise transcripts. Medical transcriptionists or health care documentation
specialists cannot remain irresponsible for these errors. Though they may not be
completely responsible for creating these errors, it is their duty to clearly identify
the same.
The future consequences of any type of dictation error can sometimes be minimal
or life threatening. Hence, dictation errors can have a significant impact on patient
health care. For instance, Roxanol is a concentrated solution of morphine sulfate
for oral administration. If the doctor wrongly overhears the dosage from 100 mg
of Roxanol every four hours instead of 10 mg every four hours, the end results can
prove to be deadly.
Important Tips for Accurate Medical Transcription
Clinical dictation is all about communicating the patient’s health history for the
next provider that’s going to be a significant part of patient care experience. The
future treatment plans or decision about what further testing patients should
undergo is made during this stage. While looking at the breakneck pace at which
technology evolves and with the health system becoming more interoperable,
even a single error can directly impact patient care, billing and data integration.
Though medical dictation errors are unavoidable, there are different ways in which
medical transcriptionists can deal with the different factors that enhance the
chances for errors. Here are some tips to ensure an accurate medical transcription
even when dictation quality is poor:
 Recheck Transcripts - Proofreading a final transcribed document is an
important step in identifying medical transcription errors. Reliable medical
transcription companies employ the services of quality control team like
editors, medical experts and proof readers who checks the transcripts to
identify errors. Along with this, certain other information like patient
names, medical record numbers and dates are double checked.

3.  Knowledge About Medical Terminology - A qualified medical
transcriptionist should have in-depth background knowledge about several
medical metrics like anatomy and physiology, lab and radiology values,
surgical and other important medical terminologies. An experienced medical
transcriptionist should have a correct understanding about different lab
value parameters, medicine dosages and what makes sense. For example, if
a doctor dictates that a particular patient has hypokalemia but his
potassium level is 8. 1, a good transcriptionist should have the relative
knowledge that these two statements do not correlate. A qualified and
experienced medical transcriptionist should have complete medical
knowledge about the following –
 What drugs work for what indication
 Normal lab values to recognize outliers
 Good training and superior knowledge of medical language, diagnostics,
medications and disease processes
 Correct context for common homonyms
 Age-related ailments
 A comprehensive understanding of anatomy and physiology to know the
exact context of the body part or system described in the dictation
 Use Reference Tools - If any case, if the transcriptionist has any doubt
related to any piece of dictation, it is essential to search for a reference tool.
Refer a drug book to check whether the dosage for a particular medication
is available and whether it is correct for the patient and situation. Also,
referring previous documents by a dictator in question can also give enough
context and clues to resolve a particular medical doubt.
 Sharpen Listening Skills - In order to deliver accurate and precise
transcripts, the documentation specialist needs to have good listening skills.
It is always better to listen to the dictation as a whole entity rather than in
different parts as this will ensure accuracy. Always not listen or just not
focus on words but be alert on what the physician meant to say. In certain
cases, there will be heavy background noises either in the dictation or
within the office environment which may prevent the transcriptionist from
clearly hearing the physician’s voice. Hence, transcriptionists need to
sharpen their listening and concentration skills to deliver correct
transcripts.

4.  Partner with Physicians - Transcriptionists, in most cases, may be
apprehensive about addressing physicians with dictation issues for fear that
they will be viewed as inefficient. However, if health care documentation
specialists approach physicians with dictation problems more proactively
this will help to create more accurate patient records. There are several
ways in which transcriptionists can partner with physicians to create
improved documentation on the front end. Do share bloopers in medical
staff meetings to accentuate the value of good habits. Also, publish the
average speech recognition scores for entire organization and then privately
share the specific scores with each physician so that they can analyze what
they stand for.
 No Guess Work - It is better for transcriptionists to leave a blank space
in the final transcript than indulge in guess work of some terms which they
are not 100% sure. In such cases, transcriptionist can flag the specific
portion in the document and later clarify it with the physician or QA
reviewer.
Medical transcriptionists need to continue their learning to keep updated about the
different changes in medical terminology or documentation. Continuous education
and training related to this field are proactive steps which medical
transcriptionists can do to minimize errors. Gaining experience in the field of
medical transcription will help transcriptionists to become familiar with the
medical jargon and to recognize correct and incorrect dictation. Professional
medical transcription companies have a trained team that can do all of this and
more.
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