Administrative medical assisting 5th by lindh chapter16

May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.. The Changing Role of Medical Transcription • Electronic medical records EMR –

Chapter 16

Medical Records

© 2014 Cengage Learning All Rights Reserved May not be scanned, copied

or duplicated, or posted to a publicly accessible website, in whole or in part

The Changing Role of Medical Transcription

• Cost conscious

• Rapidly changing economy

• Impact of new technology

The Changing Role of Medical Transcription

• Electronic medical records (EMR)

– May delegate much of MT’s responsibility to other medical personnel

– Facilitate documentation and tracking of patient care and outcomes

– Quick and easy access to accurate and readily usable information

© 2014 Cengage Learning All Rights Reserved May not be scanned, copied

or duplicated, or posted to a publicly accessible website, in whole or in part

The Changing Role of Medical Transcription

• Electronic medical records (EMR)

– All patient charts are scanned into EHR system – Partial scanning of patient charts

– Do not scan any old information

The Changing Role of Medical Transcription

• Outsourcing

– Contracting with a service outside of clinic or hospital

– Task accomplished at lower cost, faster

turnaround time

– Advantages of outsourcing

– Important considerations before outsourcing – Rapidly eliminating need for traditional

transcriptionist

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or duplicated, or posted to a publicly accessible website, in whole or in part

The Changing Role of Medical Transcription

• Voice recognition software (VRS)

– Converts voice to text using computer

– Specialized programs capable of translating highly technical medical terminology

– Continuous speech technology

The Changing Role of Medical Transcription

• Medical transcriptionist as editor

– Quality assurance (QA) manager

– Risk management

– Editor or auditor

– Flagging procedures

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or duplicated, or posted to a publicly accessible website, in whole or in part

The Changing Role of Medical Transcription

• Authentication

– Electronic signatures

• Alphanumeric computer key entries as identification

• Electronic writing device

• Biometric system

– Impact of Medicare and The Joint Commission on electronic signatures

Confidentiality and Legal Issues

• Differentiate between confidentiality and privileged information

• Health Insurance Portability and

Accountability Act (HIPAA) Regulations

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or duplicated, or posted to a publicly accessible website, in whole or in part

Confidentiality and Legal Issues

• Protocols

– Procedures your office has in place to ensure

patient confidentiality

– Confidentiality agreement

– Documentation of compliance with HIPAA

– MT usually under jurisdiction of respondeat

superior

Types of Medical Documents

• Documents part of patient’s permanent medical record

• Vital to continued patient care

• May be reviewed by

– Other providers

– Attorneys

– Insurance companies

– Court

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or duplicated, or posted to a publicly accessible website, in whole or in part

Types of Medical Documents

• Medical report must be:

– Neat

– Accurate

– Complete

Types of Medical Documents

• Common transcribed reports:

– Chart notes and progress notes

– History and physical examination reports

– Radiology and imaging reports

– Operative reports

– Pathology reports

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or duplicated, or posted to a publicly accessible website, in whole or in part

Types of Medical Documents

• Common transcribed reports:

– Consultations

– Discharge summaries

– Autopsy reports

– Correspondence

Turnaround Time and Productivity

• Hospital reports fall into four categories

– STAT reports: complete within 2 to 4 hours

– Current reports: complete within 24 hours or less – Old reports or aged reports: complete within 48 to

72 hours or less

– TAT reports: when requesting copies of your

medical record usual TAT is 7 to 10 business days

© 2014 Cengage Learning All Rights Reserved May not be scanned, copied

or duplicated, or posted to a publicly accessible website, in whole or in part

Medical Transcription as a Career

• Future of medical transcription is

changing

• Most health care providers use digital or analog dictating equipment to transmit dictation to medical transcriptionists

Medical Transcription as a Career

• Medical transcription professionalism

– Display a professional manner and image

– Demonstrate initiative and responsibility

– Work as a member of the health care team

– Prioritize and perform multiple tasks

– Adapt to change

– Enhance skills through continuing education

© 2014 Cengage Learning All Rights Reserved May not be scanned, copied

or duplicated, or posted to a publicly accessible website, in whole or in part

Medical Transcription as a Career

• Medical transcription professionalism

– Qualified MT: minimum of 2 years experience

performing medical transcription in variety of

medical and surgical specialties

– Certified medical transcriptionist (CMT)

– Registered medical transcriptionists (RMT)