Types of medical transcription reports

What are the types of reports that need to be transcribed?

A patient-provider interaction typically happens when a patient visits a doctor or healthcare provider for:

• Regular health checks
• Specific health issue
• Emergency care
• Specialist referral
• Procedure
• Surgery/ Diagnostic test 

Once the patient-doctor encounter ends detailed records need to be created of the whole process. This is not only a statutory requirement, but also aids the doctor in the treatment process, checking on the progress of the patient, providing proof in case of litigation and also used further for billing and reimbursement. Medical transcription plays an important part in the process of record creation. 

The types of reports that are created by medical transcriptionists are as follows

Patient History and physical examination report: This contains a brief about the patient name, age, gender, occupation, family health history, habits like smoking etc. and the details of the physical examination.

Consultation report: This contains the details of the findings by the consultant to whom the patient has been referred to for further treatment or diagnosis depending on the symptoms

Operative report: This contains the details of the operation/surgery that a patient has undergone including details of the procedure, duration, the anesthesia given etc. This may also contains some postoperative details.

Radiology report: This contains details of the radiologists’ findings on the X-rays, MRI scan, Ct scan, nuclear medicine, fluoroscopic studies etc along with the reports.

Pathology report: This contains the findings of a pathologist of the tissue sample.

Laboratory report: This contains the laboratory findings on body fluids

Emergency report: This is a summary of the patient’s visit to the emergency room for emergency care.

SOAP note report: This contains

• Subjective: This section contains patient’s current condition like age, gender, and pertinent symptoms etc.
• Objective: This section contains vital signs, findings from physical exams. Lab test results, co morbidity etc.
• Assessment: This contains quick summary of symptoms and diagnosis etc.
• Plan: This contains treatment plans, document goals for the patient with reasonable time lines etc.  

Progress note report: This contains progress of the patient after treatment/ operation/ procedure etc.

Therapy report: This contains details of the therapy given to the patient

Discharge summary: This contains all the details, which are generated when the patient is discharged including the treatment given, the progress of the patient, any reports and findings etc.

In light of the vital information that comes out of each patient encounter with a healthcare facility, medical transcription is an important component in the healthcare delivery cycle.

One needs to focus on a medical transcription company not just for creation of physical records but based on the following criteria:

• Accurate transcription with accuracy of above 99%
• Speedy transcription with turnaround time of 24 hours
• Reasonably priced transcription services
• Secure channels for data transmission throughout the process of transcription  

TransDyne offers quality medical transcription at reasonable prices, done by expert Medical Transcriptionists with a very quick turnaround time and executed through secure HIPAA compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

TransDyne's medical transcription service is proven and our team has vast experience in:

• Family Practice transcription
• Internal Medicine transcription
• Orthopedics transcription
• Cardiology transcription
• Neurology transcription
• Psychiatry transcription
• Radiology transcription
• Rehab Medicine transcription
• Pediatrics transcription
• Podiatry transcription
• Physical Therapy transcription
• Ophthalmology transcription
• Hematology & Oncology transcription
• ENT transcription
• Plastic Surgery transcription
• ER transcription
• Ob/Gyn transcription
• Nephrology transcription
• Urology transcription
• Gastroenterology transcription
• General Surgery transcription

To know more about TransDyne’s expert medical transcription services, click here.

A Guide to medical transcription outsourcing

What are the factors that should guide an outsourcing decision?

There are many factors that guide the outsourcing decision, profits being one of the main factors. That apart there are a few other factors that make the outsourcing decision making process easier and faster. Listed here are few of the important factors:

• Skill level of the medical transcriptionists: Quality of medical transcription is a function that totally depends on the skill set of the medical transcriptionists. While outsourcing it is important to assess the medical transcription company on the training methods used to train their workforce. Well-trained medical transcriptionists would mean that the accuracy of the transcripts would be very high. 

TransDyne recruits the best candidates through a detailed screening process to ensure that the best talent is recruited. They are then provided with extensive training in all the skills required.

The training process is taken further as TransDyne believes that it takes a specialist to take care of special transcription needs. That is why their Medical Transcriptionists are trained in one or two areas of medicine so that they become Domain specialists in that area of medicine. Specialty training assures that accuracy levels are high from the very beginning.

• Ensure that security measures taken by the medical transcription service provider are adequate: While outsourcing medical transcription it is imperative to choose a service provider, which understands the significance of maintaining confidentiality of patient data by taking appropriated security measures. 

TransDyne ensures Data security by incorporating security measures like 128-bit data encryption, multi-tiered application architecture, design level security, safeguards, firewall protected networks, sterilized e-mail servers, denial of access procedure and multi modal alerts.

TransDyne further ensures data security by ensuring that data doesn’t leave it’s premises physically. To ensure secure Medical Transcription all the transcription is done in TransDyne’s premises and the premises are secured through appropriate security measures. TransDyne meets all the HIPAA regulations.

 

·       Check on the methods and guidelines used for assuring accuracy level: Accuracy or quality of the documents transcribed is of utmost importance given the criticality of the data. Assessing the medical transcription service provider on the basis of methods used for producing accurate transcripts will show their commitment to quality.

TransDyne offers Quality Transcription with accuracy of 99% or above, while still maintaining turnaround time commitments. 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.

• Check for success stories: Nothing gives more comfort to a healthcare facility than knowing that others have benefited by services offered by the medical transcription company that they have chosen for their outsourcing needs. 

TransDyne’s website has the testimonials of the success stories of some of the healthcare leaders on the website.

• Look at the contract closely: While outsourcing the medical transcription needs of a healthcare facility one of the main risks is that the medical transcription service provider may get the work executed by hiring sub-contractors. This will not only compromise the data confidentiality but also affect the quality and turnaround time of the finished transcripts. Provisions have to be added to the contract after careful study to ensure that this does not happen. 

TransDyne believes that they can service their clients in the best possible way by having the work executed by their own team of trained and trusted transcriptionists. TransDyne believes that sub-contractors would consider the work as just another job and not apply stringent quality measures to ensure accuracy. Therefore TransDyne takes great pride in executing all the Medical Transcription work through its’ in house team of specialist Medical Transcriptionists.

• Check whether current dictation modes can be used: Choosing a medical transcription company, who does not necessitate change in dictation modes would mean a huge saving of time for doctors and also save on further capital investment for new dictation devices. 

TransDyne believes that the doctors’ time is precious and that is why flexible modes of dictation are offered. Doctors can dictate using their existing dictation devices, use digital reorders or even use mobile phones to record their dictation into the toll free numbers provided for this purpose.

Whether it is accuracy of transcripts or maintaining turnaround time or security of data or fair pricing methods or the technology used, one can be assured that TransDyne satisfies their clients on all counts.

To know more about the advantages of outsourcing to TransDyne, click here

Medical transcription: Why is dictation an important part in medical record creation?

Why document the patient-doctor encounter?

The documentation of the patient-doctor encounter takes place for a number of reasons, some of which are given below:

1. Records provide the medical history of the patient enabling healthcare professionals to administer the best care possible.
2. It is legally mandatory to maintain patient records.
3. Patient records provide the basis for referrals
4. Patient records are the basis on which insurance claims are made
5. Patient records provide evidence in case of malpractice suits. 

Having looked at the importance of having to create medical records, now the focus is on the process of record creation. Medical transcription plays an important part in the speedy and accurate creation of medical records. The medical transcription process starts when the doctor dictates notes of the patient encounter into a recording device.

Many people have questioned the necessity of the doctors dictating notes rather than directly typing out the reports. Let us examine why dictation is necessary:

Time: Time is a scarce commodity for healthcare professionals and dictating free style could be squeezed in at any time of the day, and would not require any equipment other than their phone.  Dictating notes would also take less time than actually typing as it has been proven than people can talk faster than they can type.

Expertise: The skill set of a doctor may not necessarily include typing speedily and accurately.

Speed: A medical transcriptionist could have better typing speed than a doctor. Moreover the creation of patient records would be speedier by medical transcriptionists as this is their only work; therefore the focus is totally on this.

Ease of use: It is easier for the doctor to dictate into his recording device while doing other things than to sit and type out the report.

Expense: It is cheaper for a medical transcriptionist to transcribe the report rather than the doctor waste his expertise and productivity on this task.

It is therefore better for doctors to focus on their business; providing quality healthcare and for the medical transcription service provider to focus on their business; Expert medical transcription and medical record creation. 

How to improve dictation quality?

We have looked at the advantages of dictating vis-à-vis typing, now let us focus on how dictation can be improved to improve the accuracy of the transcribed reports: 

Given below are a few dictation tips towards accurate medical transcription:

• Allot time for dictation: This will help the doctors to complete documenting the patient encounter when their memory is still fresh and capture all the details.

• Allot space: Allotting a convenient space for dictation will ensure that factors like noise, distractions do not affect the quality of recording.

• Collect papers: Collecting all the documents/reports required will help the doctor finish dictating accurately in less time.

• Speak at a steady pace: Speaking a steady pace will ensure that words are not garbled and help the medical transcriptionist focus.

• Spell difficult terms: Spelling difficult terms will ensure that the data captured is accurate.

• Rewind and listen: Sometimes rewinding oneself and listening to the dictation will help clarity by highlighting the areas for improvement.

• Know the equipment: Knowing the equipment being used for dictation will help the doctor to modulate his dictation, mike distance, stop/start features etc.

• Relax while dictating: Treat the time spent dictating, as time for a break and this will help the doctor relax and capture all details.

• Pause during interruptions: In case of any interruptions, it is better to use the pause button so that extraneous data is not captured. 

Following these simple instructions will go a long way to help create accurate transcripts at an optimum turnaround time

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time executed through secure HIPAA & HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

For more details about how to use TransDyne’s superior outsourced medical transcription services, click here.

Medical transcription outsourcing & Data security

Is outsourcing of patient records really unsafe?

There have been serious doubts about data security while outsourcing medical transcription. The case of Lubna Baloch from Pakistan who threatened to expose confidential data over the Internet for non-payment for services rendered has been used as an argument against outsourcing.

It is understandable that situations like this are worrisome and very traumatic for all parties concerned. But can this be cited as a case against outsourcing? To answer that question one needs to look at the case in question in great detail.

Let us examine the chain of events that led to the event in question:

UCSF medical Center outsourced it medical transcription work to

¯

Sausalito’s Transcription Stat who outsourced it to

¯

15 contractors throughout the country

¯

One of the 15 contractors named Sonya Newburn further subcontracted the work to

¯

Tom Spires who subcontracted to

¯

Lubna Baloch

It can clearly be seen that the healthcare facility originally outsourcing its’ medical transcription needs had no idea as to who is actually doing their work. Even the medical transcription service provider who was under contract with them had no control over the end transcriber.

The lesson to be learnt from this situation is that while outsourcing the medical transcription needs of a healthcare facility, care should be taken to ensure to choose a medical transcription service provider that does not use sub contractors for executing the work. Due diligence on the working methods of the medical transcription service provider should be carried out; care should be taken at the time of drafting the contract to ensure that the “no sub contractor clause” is included. 

TransDyne is one company, which believes it is their privilege to be serving their customers’ needs in the best way possible. So any work outsourced to TransDyne, is executed by their own team of trained Medical Transcriptionists, than by the use of subcontractors or home transcriptionists.

Apart from ensuring that the data never leaves the premises physically, TransDyne ensures security during the medical transcription process by incorporating security measures like 128-bit data encryption, multi-tiered application architecture, design level security, safeguards, firewall protected networks, sterilized e-mail servers, denial of access procedure and multi modal alerts.

Further security is ensured by manned security at entry and exit points, surveillance cameras, disallowance of any removable storage devices and limited access of systems and information on a need to know basis. The people working on the transcription have also been educated on the importance of being HIPAA and HITECH compliant.  Undertakings have been taken from the personnel to further ensure confidentiality.

Choosing a professional and committed medical transcription service provider like TransDyne would ensure that the healthcare facility would enjoy not only the cost saving benefits of outsourcing and the knowledge that patient data confidentiality is maintained but also the other benefits of outsourcing like:

1.     Reducing capital investment with regards to medical transcription

2.     Managing fluctuating transcription report volumes and staffing issues for holidays and weekends.

3.     Reducing management expenses towards medical transcription

4.     Reduce human resources expenses connected to medical transcription

5.     Reduce direct labor cost

6.     Reduce It expenses

7.     Reduce real estate cost pertaining to medical transcription

8.     Improve information access

9.     Improve turnaround time

10. Shorten the receivables cycle

11. Concentrate on core business

12. Take advantage of a single source solution

TransDyne offers quality medical transcription at reasonable prices, executed by experienced and qualified medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!            

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

Software and tools for medical transcription

What is the role of software and tools in the medical transcription process?

The process of medical transcription has evolved a long way from where it started. Gone are the days of sending records/ tapes through courier and receiving the finished transcripts in a similar manner. It is the digital age and technological advances have made it possible for the whole process to be fast and safe.

Time is a resource which is scarce for health care professionals therefore it becomes important that the medical transcription company chosen to take care of transcription needs should utilize technology which is advanced and secure and also simple to use.

The role of software and technology in the transcription process is as follows:

• Dictation: Doctors need to have flexible options for dictating their notes so as to utilize their time in the best way possible.

• Upload of documents: The dictated records then need to uploaded so that the process of transcription can take place

• Delivery of finished transcripts: Once the audio records have been transcribed these need to be made available to the doctors for further use.

• Archives:  Medical records play an important part in many ways like further treatment, referrals, statutory requirements, billing and as evidence in case of litigation. Therefore it becomes important that the records are easily accessible.

• HL7: Healthcare information may need to be further transmitted to various sources; the medical transcription company needs to have HL7 integration to make this possible. HL7 is a protocol developed for communication of health data to various entities without the meaning getting lost. 

TransDyne a leading name in medical transcription believes that technology needs to be advanced so that the service provided is of the best standard, but should be simple to enable ease of use for healthcare professionals.

Some of the features of the software and tools used by TransDyne are as follows:

• Smart upload: TransDyne offers doctors the choice of using modes of dictation they are already comfortable with. Then these files can be uploaded to the servers to be made available for transcription. Smart upload enables transfer of dictation files from the healthcare facility’s server to TransDyne’s server by checking for new dictations at pre-fixed intervals.

• Web Delivery: TransDyne’s web delivery system tackles all issues related with tracking dictations, receiving documents and finding old files form the archives.

• Smart Delivery: Smart delivery is an automated program that addresses the automatic downloads, saving files and printing needs of a healthcare facility.

• HL7 integration: TransDyne can configure and send healthcare information as HL7 messages to the client’s EMR with no additional costs. 

TransDyne offers quality medical transcription at reasonable prices, done by expert Medical Transcriptionists with a very quick turnaround time executed through secure HIPAA compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use. 

To know more about the superior medical transcription services provided TransDyne click here.

Medical transcription: Testimonials

When a healthcare facility looks for outsourcing options it is acknowledged that this is a major decision that will have a long-term impact on their business. Researching for the right medical transcription service provider to be a partner for back office needs can be both time consuming and confusing, due to the abundance of information available at ones’ fingertips.

It is accepted that one needs to evaluate a medical transcription service provider in terms of accuracy, turnaround time, pricing and data security.

• Accuracy: This means the percentage of accuracy of the completed transcripts vis-à-vis what was dictated. A minimum of 99% and above would be acceptable.

• Turnaround time: Turnaround time refers to the time taken to revert the transcribed report to the healthcare facility. A Turnaround time of not more than 24 hours for normal reports and 4-12 hours for STAT reports would be considered ideal.

• Data security: The Company being outsourced to should be HIPAA compliant. The Medical Transcription Company has to have adequate security measures to ensure that the confidential data transmitted back and forth is safe and secure.

• Pricing: This is one of the main benefits that a healthcare facility hopes to have, from the outsourcing option. Pricing should be fair and reasonable for the services rendered. Pricing method should also be transparent and simple so that both parties can verify the same at any stage of the process

• Technology: The technology used by the Medical Transcription Company should not only secure but should also be easy to use, without having to require extensive training. 

Once these have been ascertained one needs to look for a medical transcription service provider who can actually “walk the talk”. That is to say the medical transcription company needs to be able to prove that they can actually deliver what they promise.

The one way they can do this is by providing testimonials of other healthcare facilities that have already benefited from their excellent services and are willing to acknowledge it. Having testimonials validates one’s decision and gives the right direction to the decision making process.

This gives the healthcare facility:

• Confidence: A decision making process can involve a lot of analysis of one ‘s own organization and the needs that one needs to fulfill through the outsourcing process. Having testimonials gives confidence that the right decision has been made.

• Comfort level: The comfort of knowing that the services promised have actually been delivered can lead to faster adaptation and implementation.

• Confirmation: It gives the healthcare facility confirmation that they have the right partner for their medical transcription needs

• Conversion: The process of conversion from the healthcare facility’s current medical transcription service to that of the medical transcription service provider becomes smoother and seamless due to the confidence and comfort of having similar success stories in the form of testimonials. 

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use. Not only that they are proud to share their success stories with prospective clients.

TransDyne’s website has the testimonials of the success stories of some of the healthcare leaders they have served. To avail excellent medical transcription services from TransDyne, click here.

Medical Transcription services

What is transcription and how does it relate to the field of medicine?

Transcription is conversion of audio files to typed records in a paper form or in the form of computer files as per specified formats. Medical transcription is the conversion of audio files of a patient encounter as dictated by a healthcare professional into a typed version, which is then stored in the form of paper records or as a computer file.

Why is medical transcription needed?

Records of patient encounter need to be created and maintained for various reasons such as Patient treatment, Permanent Patient records, Referrals to other doctors, Evidence in case of malpractice suits, Coding, billing and insurance claims and Satisfaction of regulatory norms. Medical transcription plays a vital role in creating accurate records of patient encounters with the doctors.

How is medical transcription done?

After the patient encounter, the healthcare professional dictates notes regarding the encounter into a recording device of his choice, which is then transcribed by a person skilled in this kind of work having knowledge of medicine, latest drugs, procedures and good language skills.

When is medical transcription done?

Once the doctor has finished dictating notes these are then transmitted to the medical transcriptionist using various means, the actual transcription is finished within a period of 24 hours at the latest. Priority is given to STAT files and these are returned earlier.

Who does the medical transcription?

Medical transcription is done by in-house medical transcriptionists or through outsourcing to a medical transcription service provider who specializes in this kind of work.

It has been argued that doctors could themselves create records as and when they finish with the patient encounter. But this has been proven to curb the productivity of doctors in terms of time spent typing (which is not necessarily their core skill) and reducing the time spent on care of patients.

Why outsource medical transcription?

Outsourcing medical transcription can benefit a healthcare facility in various ways. If helps them to focus on healthcare which is their core business rather than medical transcription which is not. It also improves profitability by freeing up valuable resources like manpower, capital and time etc which would otherwise be focused on medical transcription.

Having understood the importance of medical transcription and the benefits of outsourcing, one needs to choose a medical transcription service provider that excels on the following criteria:

• Accuracy: This means the percentage of accuracy of the completed transcripts vis-à-vis what was dictated. A minimum of 99% and above would be acceptable.

• Turnaround time: Turnaround time refers to the time taken to revert the transcribed report to the healthcare facility. A Turnaround time of not more than 24 hours for normal reports and 4-12 hours for STAT reports would be considered ideal.

• Data security: The service provider being outsourced to should be HIPAA compliant. The medical transcription company has to have adequate security measures to ensure that the confidential data transmitted back and forth is safe and secure.

• Pricing: This is one of the main benefits that a healthcare facility hopes to have, from the outsourcing option. Pricing should be fair and reasonable for the services rendered. Pricing method should also be transparent and simple so that both parties can verify the same at any stage of the process

• Technology: The technology used by the Medical Transcription Company should not only secure but should also be easy to use, without having to require extensive training. 

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology for transcription  that is advanced but easy to use!

To know more about TransDyne’s superior medical transcription services,  click here.

Medical transcription: Questions a healthcare facility needs to ask before finalizing a service provider

There are certain things a healthcare facility needs to know before making the important decision to outsource their medical transcription needs. Knowing the medical transcription service provider well can improve the transition process, reduce miscommunication and have a synergetic effect on the business by creating a long-term partnership

Apart from knowing the accuracy level of transcription offered, the turnaround time promised, the pricing offered and the measures taken for data security defined, there are certain questions that need to be asked. These will help the healthcare facility become comfortable with the medical transcription service provider. What are the questions that need to be asked?

Question no.1: How long has the medical transcription service provider been in the business of medical transcription? Can they provide Client testimonials on request?

Asking this question will clarify the history of the company in the field of medical transcription and the experience they have in providing quality service to others. It will also establish that the medical transcription service provider being considered is not a fly-by-night operator. Considering the criticality of work to be outsourced it is very important to have Client testimonials of those who have availed the services of the company.

TransDyne has been providing outsourced medical transcription services for more than a decade. TransDyne has a huge base of satisfied customers who have availed of their expert services. Some of their client testimonials are available on their website.

Question no.2: How much is their capacity for medical transcription on a monthly basis?

The answer to this question will clarify the capability of the medical transcription service provider in handling a large quantity of work while still providing the requisite quality. The healthcare facility would be able to then benefit from the large pool of qualified and trained manpower available to them.  This would clarify that the medical transcription service provider can provide Expert medical transcription

TransDyne has a huge pool of trained medical transcriptionists who are capable of handling huge volumes of transcription without compromising accuracy or turnaround time. TransDyne has gone a step further by training medical transcriptionists in one of two area of medicine making them specialists in that domain.

Question no.3: What are their quality processes?

This will clarify the medical transcription service provider’s commitment to quality medical transcription and whether they give due importance to having processes in place to ensure that the accuracy of transcripts is maintained to the highest level possible. Existence of quality checks and quality guidelines will establish the credibility of the medical transcription company

TransDyne offers Quality 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

TransDyne has Quality Guidelines for Medical Transcription in place that ensure that nobody or nothing is indispensable. The only thing that TransDyne considers indispensable is the quality of work!

Question no.4: Does the medical transcription service provider have professional and proficient customer service staff?

At every stage of the transition to a new service provider for medical transcription it is important to have helpful and well informed customer service personnel answering your queries so that all the kinks can be ironed out from the beginning. Having a responsive and knowledgeable customer staff can go a long way in establishing a good relationship

TransDyne believes in being available to the customer 24/7 so that any doubts/clarifications are sorted out at the earliest.

Question no.5: What is their technological capability? Are they HIPAA compliant?

For a healthcare facility it is important that their medical transcription service provider uses technology, which is safe and secure, for HIPAA compliancy and advanced enough to accommodate all required functions. Having the right software tools, which are easy to use can make it easy for health professionals interact with it

TransDyne believes that technology should not only be advanced, but also be easy to use for the end user. TransDyne has made it very easy for the doctors to upload their dictation through various devices and also down load the transcribed files in a simple manner.

TransDyne ensures Data security of Medical Transcription by incorporating security measures like 128-bit data encryption, multi-tiered application architecture, design level security, safeguards, firewall protected networks, sterilized e-mail servers, denial of access procedure and multi modal alerts.

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time executed through secure HIPAA & HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

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