Introduction

Medical records are a combination of self-reported patient information and Medical notes on the patient’s diagnosis, care, and treatment. When a patient visits a physician, the latter uses a digital recording system to establish a diagnosis and transcribe the patient’s medical status. 

Many doctors use medical transcriptionists to convert these recordings into correct medical records. Most provide facilities now have EHR systems in place, and transcriptionists may access the physician’s EHR and submit correct medical information via an HL7 interface. Medical records must be documented accurately and on time.

In the medical industry, accurate medical records are a critical component of providing effective patient care.

To ensure your patient receives the best treatment possible and to protect yourself from a complaint, you’ll need detailed proof outlining each encounter – all while ensuring your record management satisfies stringent GDPR compliance and regulatory responsibilities.

To assist you in understanding best practices for maintaining medical records, we’ve defined what makes up a medical record and the top ten principles you must follow to provide patients with the best treatment possible.

Importance of Accuracy in Medical Records

A medical record is crucial in a patient’s life since it is a significant instrument for giving accurate and trustworthy information about a patient’s health history. In many circumstances along a patient’s life journey, this data acts as a genuine and key source of reference.

When medical errors occur, most people want to know why they occurred. The medical record is ‌one of the first areas they look at. Because of their extensive information, most records can help determine where errors occurred. In consequence, they can help provide better treatment to patients. Accurate records may also aid in the settlement of malpractice lawsuits.

Erroneous records may prove to be liabilities. If faulty recording results in errors, you may face a lawsuit. As a result, your responsibility should be to always enforce correct record-keeping standards.

Best Practices Ensuring Accuracy in Medical Record Summaries

Medical records must be accurate at all times. Healthcare practitioners can only build an effective treatment plan and deliver the required care if they have the correct medical records. Medical transcription errors can have serious financial, legal, and patient health consequences. Furthermore, critical operations such as medical coding and invoicing, backup for prospective audits, and Meaningful Use certification rely on the accuracy of medical information. High-quality audio is required for accurate transcription.

Here are some guidelines for ensuring high-quality audio and other prerequisites for producing high-quality medical transcripts.

• The following names should be available to medical transcriptionists: All names, including dictating authors and referral doctors, should be available to MTs. If you use an electronic signature, ensure that you provide the medical transcription provider with written consent and a duplicate of your handwritten signature ahead of time.
  
• Speak loudly: Talk normally, and the recorder should be around 34″ from your lips in an upright position, depending on the microphone used. This allows the sound to pass across the microphone rather than straight into it. If you’re filming with a smartphone or tablet, be sure your hand doesn’t cover the microphones.
  
• Be cautious of tricky terms: Medical language is complicated, and new words are constantly being introduced. Then there are terms that sound similar and cause misunderstanding or spelling errors. When employing such terms, exercise extreme caution. Medical transcriptionists should ideally use reference materials such as Stedman’s Medical Dictionary for double-checking. They should never try to guess a word because this might lead to misunderstanding. If the terms are unclear, it is advisable to leave a blank space in the transcript until the phrase is defined. Questions about numerical descriptions or units of measurement should also be answered.
  
• Begin with comprehensive and accurate demographics: Patients should be recognized unambiguously, and all of their data should be provided at the time of dictation. Begin dictation by giving their record number, relevant dates, and report type. This will prevent misunderstanding and the recording of incorrect patients.
  
• Send only encrypted files: Data breaches carry severe fines. HIPAA compliance is critical, and patient privacy must be protected at all costs. All files must be encrypted before being sent to the transcribing service provider. Follow the process for transmitting and receiving files established by your hospital and the medical transcribing business. The medical transcribing business may give specialized software for extended recordings. Emails should not be used to send data because they may not provide security.
  
• Quality assurance is essential: Make certain that your selected firm can guarantee quality. Quality should never be sacrificed since it jeopardizes patient safety and care.
  
• Avoid a loud environment: For best outcomes, choose a secure and peaceful setting. Avoid settings that contain distracting background noises. Avoid distractions such as phone rings, music, vacuums, and beepers when dictating.

Final Thoughts

Medical reports must be accurate for any hospital, clinic, or healthcare institution, and outsourcing Medical record summarization services in India, US, UK is a practical way to accomplish this. The aforementioned suggestions can help ensure more clarity in the transcripts.

Apart from producing clear audio, maximum attention should be paid to workflow details such as providing complete and correct information, alerting the transcriptionist to any special instructions, clearly identifying STAT or amended reports, and securing file transmission to achieve excellent quality transcription.

Ready to enhance your medical reports? Explore our professional summarization services today.

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