Medical Transcription

Written by Norene Anderson
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Medical transcription is a method of producing one of the many vital documents that become a part of the permanent record of every patient. It does not matter if a patient is seen in a clinic or admitted to a hospital. Every physician treating the patient must document everything done in the course of treatment. Accurate record keeping is an absolute necessity for future reference and to meet the stringent requirements of insurance companies and government regulations.

Most large medical facilities use in-house medical transcriptionists. The cost factor is absorbed in the luxury of having the work done on the premises. While this may work for the larger facilities, it is cost prohibitive for many of the smaller medical practices or small hospitals. One of the out-sourcing ways that has been used for years requires transcriptionists to pick up a dictated tape, take it home, transcribe the information, then return the finished copy to the office or clinic. This is a very time consuming and cumbersome way of getting the desired results.

Requirements for Medical Transcription

Computer technology has had a great impact on how medical transcription is done today. There are now companies that offer transcription service online. The requirement for privacy according to the HIPAA (Health Insurance Portability and Accountability Act) that was passed in 1996 has placed many restrictions on the handling of patient information.

In order to comply with HIPAA, medical transcription services must use every precaution to preserve the integrity of the dictated information. This requires some type of web security such as 128-bit SSL encryption technology. Some services use 256-bit encryption. HIPAA also requires that all email messaging and document transfer meet the strict guidelines to guarantee privacy protection of the patient records.

Dictation Methods

Medical transcription services will typically provide the physician with a digital handheld recorder as part of the service agreement or the physician may purchase one separate from the transcription service contract. If a physician has not dictated digitally, there is a short learning curve to master a new technique. Once the method is learned, it will save a lot of time over the old method.

The information is dictated onto a smart card and then sent via the Web to the server of the service provider. It is then picked up by the transcriber as assigned. In most cases, medical transcription is completed within a 24-hour window. This gives the doctor almost immediate access to the record following the visit. This is crucial when dealing with an extremely ill patient.

Medical Transcription Services

Many services also offer the option for the physician to call an 800 number and dictate the reports. The advantage of the digital dictation is the freedom to dictate from any location rather than being confined to the locality of a phone. Once the reports are transcribed, there is always immediate access for the physician to review any report on any patient at his or her convenience.

The transcriptionist must have a computer set up to meet the strict HIPAA confidentiality guidelines. It must also be able to handle some type of transcriber software and device to control the dictation speed for accurate translation. It is vital to have a dependable PC capable of handling the load and communicating effectively over the Internet. The technology for improved medical transcription is constantly advancing.

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