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Medical Transcription Outsourcing - Helps Create Legally Compliant Documents
Author : Rene Kendrick
Submitted : 2011-03-25 02:12:05 Word Count : 507 Popularity: 7
Tags: medical transcription outsourcing, clinical documentation, health information management
While documenting the patient- healthcare professional encounter has an impact on the process of providing care and for coding purposes, another important aspect of documenting the patient encounter is that of meeting compliance standards so as to provide valuable support for risk management. Healthcare facilities have various options available to them for documenting the patient encounter, more so now due to the changes in the documentation scenario. Each option available for documenting the process has its own pros and cons.
However keeping in mind the valuable role played by patient medical records in the smooth running of healthcare facilities it is important to pick a method of documentation that is preferred, convenient, easy to use and most importantly helps document the patient encounter in a manner that supports the legal and compliance aspects. It has been found that medical transcription services meet all these criteria. As this process is a specialized service requiring a combination of the right team, the right technology and the right process to meet all these criteria, outsourcing medical transcription to a professional transcription vendor has been found to be an effective solution.
How do outsourced medical transcription services help create legally compliant patient medical records?
To meet legal requirements a medical transcript by definition must meet all statutory, regulatory and professional requirements for clinical purposes as well as for business purposes. Patient medical records should meet the norms like:
· A unique medical record should be created and maintained for each patient.
· The medical record should include author of the record, date of the encounter, time of treatment, and authentication as appropriate
· It should be accessible and also meet all security and confidentiality norms
· It should be created according to the procedure required for forms, template etc for specific reports
· The retention, archiving, destruction (of defunct) records should have appropriate procedure to enable data quality management.
Outsourced services help in all these aspects of quality data management by providing services with the following benefits:
· The patient- healthcare professional encounter is transcribed in its entirety to include all the details as required.
· The identifying information provided by the healthcare professional is recorded carefully along with the detailed record of the diagnostic and treatment procedure.
· It is ensured that the patient medical records are made easily accessible by delivering the transcripts through the modes specified by the doctors/support staff/clinics/hospitals, using HIPAA and HITECH compliant channels
· Transcripts are created as per the specific template/ format required for the specialty and as specified by the doctors/support staff/clinics/hospitals.
· A system for archiving transcripts is provided that allows for easy access. Older transcripts are archived as per the specific requirement of the doctors/support staff/clinics/hospitals to enable easy data management.
It can be seen that outsourcing medical transcription enables proper and descriptive documentation of the patient story retaining the narrative while still enabling adoption of EMR/EHR using HL7 interface.
Author's Resource Box
Renee Kelly has written numerous articles on medical transcription service, which has served as an amazing resource for healthcare facilities and healthcare professionals seeking the services of a professional medical transcription company.
Article Source:
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