Medical Transcription: The Beginning and the End

Medical transcription has become popular both as a profession and as a service needed by healthcare facilities. Though most people are aware of medical transcription as a process of converting audio files of a patient-healthcare professional encounter into a text format, the role played by this service is still not clear and is often confused with Medical billing or that of a medical secretary.

Medical transcription is more than just the conversion of audio files of the patient-healthcare professional into text format. Patient records play an important role in the following:

1. Patient treatment: Information plays a vital role in continuity of patient treatment. Factors like age, sex, occupation; lifestyle, allergies, previous treatments & medication etc are vital to the ability to provide quality care. The transcription process plays an important role in recording these details as accurately as possible.

2. Permanent Patient records: This process creates records of the patient-healthcare professional encounter to form part of the permanent patient record. This enables the healthcare professional to draw information from a reliable source rather than depend on his/her memory or the patients themselves. The medical record containing the patient’s medical history is especially important while providing emergency care, where the patient is not in a condition to provide details about himself/herself.

3. Referrals to other doctors: A patient may be required to be referred to a specialist for further treatment. In this case the medial record provides information of the findings and treatment given till date and prevents wastage of resources by preventing duplication.

4. Evidence in case of malpractice suits: In case of litigation the medical record provides important evidence of the process of healthcare provided by the healthcare professional. Documenting the patient-healthcare professional process in detail can lessen the ambiguity and clear the healthcare professional of any malpractice.

5. Satisfaction of regulatory norms: The law requires that the patients’ record should be maintained by the healthcare facility for a minimum period of time.

The role of patient records is not just limited to the healthcare aspect. It also plays a vital role in the accounts receivables cycle. The information recorded in the patient’s records form the basis of:

· Coding: Based on the information in the medical record coding is done as per CPT (current procedural terminology) and ICD (international classification of disease) with the help of coding books and maintaining coding guidelines.

· Billing: The bills are then generated as per the coded records, which are then sent to the relevant insurance providers for claims.

Medical transcription plays a vital role in both the provision of quality healthcare as well as the commercial aspects. It starts with the patient-healthcare professional encounter and continues to play an important role in collections as well as providing information for other factors like research, profiling of diseases, prevention of epidemics and preventive disease management.

Considering the vital role played by this service, choosing a service provider requires careful consideration. The service provider needs to be assessed on the basis of accuracy, turnaround time, security, pricing and the technology used.