Thursday, June 24, 2010

Medical transcription: What are the methods of quality assessment?

Quality is an important criterion in any decision making process. Assessing quality becomes even more important when it comes to availing service as critical as medical transcription. Medical transcription is the process of converting audio records of a patient- healthcare professional encounter into a text format.

The accuracy/quality of medical transcription critical as this forms the basis of:

  • Permanent patient history
  • Present and future treatment plan and basis for monitoring progress of the patient
  • Referrals/tests/procedure
  • Statutory requirements
  • Evidence in case of disputes/litigation
  • Accounts receivable processing
It is important that records that play such an essential role be of the highest accuracy/quality possible. While making the decision to outsource medical transcription needs it is vital to ensure that the medical transcription service provider has HPI guidelines in place for assessment of quality.

What are HPI guidelines?
The concept of Quality Assessment (QA) began in 1990 when a format was developed by Judy Hinickle to assess quality of transcription. This was followed by presentations made to thousands of transcription supervisors and educators around the country by Health Professional Institute (HPI), Association for Healthcare Documentation Integrity (AHDI), American Health Information Management Association (AHIMA), and Medical Transcription Industry Association (MTIA).

Health Professions Institute then adapted and promoted this for its standard-setting SUM program for medical transcription. This QA method is the basis of most programs and is of most thorough and effective nature, embracing true Continuous Quality Improvement concepts.

TransDyne executes medical transcription using quality guidelines by HPI

What do HPI guidelines consist of?
HPI guidelines consist of quality check parameters and computing system for quality satisfaction and highest accuracy levels. HPI guidelines are categorized as follows:

  • Error 1. Medical Word misuse-Point 1.00: This is considered one of the most serious errors as it can affect every aspect of treatment administered to the patient. Even billing information is affected by this error. Guesswork or making up of words when dictation is not understood is also included in this error category.
  • Error 2. Omission- Point 1.00: This is also considered an equally serious type of error as it reflects poorly on the ability and professionalism of the medical transcriptionist.
  • Error 3. Medical word misspelling- Point 0.75: This is the incorrect spelling of medical terminology.
  • Error 4. English word misspelling or Misuse -Point 0.75: This includes misspelling of English words nouns, verbs, qualifying adverbs etc, which could have a serious consequence.
  • Error 5. Inappropriate blanks- Point 0.75: These refer to blanks that are left unfilled, and those, which could be filled up by extensive research by the medical transcriptionist.
  • Error 6. Grammar errors- Point 0.5: Grammar errors include incorrect use of medical abbreviations, misuse of words, misuse of parts of speech, misuse of subject-verb, singular/plural misuse, etc.
  • Error 7. Punctuation errors- Point 0.5: Include errors with regard to punctuation like coma, colon, semi colon etc that change the meaning of the sentence if misused.
  • Error 8. Typographical errors- Point 0.25: Minor grammar, punctuation or capitalization errors.
  • Error 9. Formatting errors- Point 0.25: This error refers to the prevailing departmental/physician guidelines for placement of certain information within the document. E.g. Headers, Footers, templates as defined by the client.
Having these quality guidelines in place ensures that everybody in the TransDyne team is guided by the same principles. TransDyne offers quality medical transcription with accuracy of 99% or above. TransDyne ensures quality by adopting a four level quality check of medical transcriptionist, language proofreader, unit in charge and finally by the quality assurance team which tries to minimize errors before returning the finished reports.

To avail superior medical transcription services from TransDyne, click here.

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