Medical transcriptionists understand that the medical record is a legal document, and handling such sensitive information requires the utmost of professional ethics and confidentiality. Because of the confidential relationship between the physician and the patient, each medical record must remain absolutely confidential.
As a working MT you should never relay patient information to outside parties. It is very important to take the security of the patient record seriously. This means that even if you are transcribing your best friend's reports, the fact that you do so should never be discussed.
Most facilities and MTSOs (medical transcription service owners) require the transcriptionist to sign a confidentiality statement upon hiring, and violation of this is cause for termination and possibly legal recourse. Make it a practice to transcribe your reports, proof and edit them, and then forget about them. Most confidentiality has been broken because transcriptionists talk to their friends about an unusual problem she has encountered in a medical record. The problems that could occur with this are:
A. Somebody could overhear you, and that somebody could be a relative of the patient.
B. Your friend could know the patient in question and spread the news even further.
C. You portray a less than professional image when discussing contents of medical reports.
Ownership of the healthcare record belongs to the facility, but the patient is entitled to copies when a written request has been issued. Unless it is your job specifically, the medical transcriptionist should never make copies for the patient when requested directly by the patient or a family member. Remember, your job is to keep the records confidential at all times.
There are new guidelines concerning medical records in a set of laws called HIPAA (Health Insurance Portability and Accountability Act.) Parts of the HIPAA laws discuss the handling of medical records, and this could affect MTs that work at home. MTs who work at home are being encouraged to take measures to protect any information on their computers or on floppy disks. Some of these measures include password protecting your computer, keeping your virus definitions up to date, and locking any floppy disks that may contain confidential information in a file cabinet or box. It's also important not to let anyone have access to the part of your computer that contains vital patient information and diagnoses. One transcriptionist I know was haphazard about doing so, and her husband's boss's medical reports were discussed. This type of thing is in direct violation of HIPAA Federal laws and could have serious consequences. Therefore, always protect your information on your computer (and shred any trash with patient names) once you begin working on the job.
Many MT services are now using “encryption” to send/receive medical records through e-mail. Encryption is a process that uses special encryption software to protect the electronic transfer of medical records. One of the more popular types of encryption programs is Cryptext which is inexpensive and very easy to use. We will explore this software and more later in the course.
Electronic signatures are popular methods of signing medical reports by the dictating physicians. This means that the physician’s typed name on the report is sufficient instead of a physical signature. Electronic signatures, however, open the door for errors that would not be caught because the physician is not reading or signing the reports. Because of this, it is vitally important that the medical transcriptionist have a complete understanding of the dictation they are transcribing in order to ensure they are transcribing exactly as the doctor dictates. That's just another reason why a good MT course is important to your career!
When we talk about professional image usually the picture that comes to mind is dressing professionally and conducting yourself well in an interview situation. Since it is common for MTs to work at home, you may never actually meet your employer. So what does professional image mean in this context?
MTs need to be trustworthy, dependable, and competent because we deal with confidential medical records. From the first contact with a prospective employer it is important to begin projecting these characteristics immediately.
How can you project trustworthiness and dependability? You can do this by simply doing everything that you agree to do. In other words, if an employer wishes to schedule a telephone interview with you and you set up a time to talk at 2 p.m., make sure that you are on time and prepared for the interview. You could have a list of questions to ask or a list of your qualifications to discuss over the phone. This will project both trustworthiness and dependability. (In Module 30, we cover this in much more detail, including how to get business on your own.)
How can you project competence before you are hired? Competence comes through in your resume. Is it neatly arranged? Is it perfect grammatically without typos, misspellings or grammar errors? Also, most companies will give you a transcription test to complete before making a final hiring decision. You will be evaluated on how quickly you complete the test, neatness, organization, style, grammar, punctuation, and a basic knowledge of proper formatting procedures. (Don’t worry -- in Module 30, we cover these items completely.)
Also, many MTs forget that following the instructions for the test (example: how to download, instructions for formatting, instructions for sending it in, etc.) may be as important as the test itself. Employers want to know that you are able to handle all aspects of the testing process with ease and confidence which exhibits the trait of competence.
Also, it is important to note that there are differences between the work environment of MTs that work in a hospital or clinic and those that work at home. MTs who work at home can dress casually or even not get dressed all day. Whereas, MTs who work in facilities such as a hospital or physician’s office would need to pay attention to how they dress, wear their hair and makeup, etc. to project a professional image. The at-home MT does most of their image projecting over the phone and through personal correspondence like e-mails, faxes, etc.
As mentioned earlier, at the conclusion of your training at MTACC you will work through our employment and technology modules. These modules will explain how to prepare proper resumes, interviewing techniques, and testing procedures. We'll help you to prepare a professional resume if you don't already have one. Additionally, by the end of your studies with us, you will have a professional image already in place, and your skill level will be more than competent. We also help you with job placement! We believe in our graduates and will do everything in our power to help you to excel in your new career!
Right now some MTs are concerned because some work is being sent overseas, especially to India India charge such a low line rate (.03 cents per line) some MTs are afraid that the line rates in the USA US
Another concern some MTs have is the advent of voice recognition software. This is software that allows the doctor to speak into a microphone and the software translates the voice into text. This is not widely used for many reasons. First, the equipment is expensive and takes time to “train” to the doctor’s specific voice. Secondly, many ESL dictators commonly mispronounce certain English syllables and sounds, and that would make voice recognition unusable. Lastly, no software can be sensitive enough to distinguish between sound-alike medical words like “Xanax” and “Zantac.” If voice recognition is ever perfected ten years in the future, MT editors would still be needed to edit the final documents.
There is a law called HIPAA (Health Insurance Portability and Accountability Act) which includes some provisions in the handling of patient medical records and the security of them. Basically, there is some confusion about how HIPAA guidelines will affect work at home MTs. Right now it is thought that simply password protecting your computer, using encryption software (will explain more on this later in the course), and locking up floppy disks that contain patient information in a file cabinet will be sufficient. You will learn much more about HIPAA in module 30.
MT services are switching over from the old “tape and transcriber” method of transcribing medical reports to using Wav files/Wav pedals and the Internet to send and receive dictation. This is a very efficient and inexpensive way of doing business! You will learn in our course all about how to use a WAV pedal to transcribe Wav files. Basically, in brief, a WAV file is a computer sound file that can be played on your computer using special software.
Learning Digital Dictation
Digital dictation is a way to send/receive dictation using your computer and the internet. It involves the use of either call-in systems or hand held recorders. You will learn more about this in the presentation that follows. Because digital dictation is easier, faster and cheaper than the old cassette tape/ transcriber system, many companies use some type of digital system.
As a medical transcriptionist it is important to understand how digital dictation works. Employers want to hire computer literate MTs. The presentation that follows is short and concise explanation of how digital systems work.
Don’t worry if you don’t completely understand everything in the presentation. You will get actual practice during the transcription portion of the course using a foot pedal, FTP software and downloading dictation from our server. Sit back and enjoy!
History and Physical (H&P): This report is usually dictated by the admitting physician or resident when a patient is admitted to the hospital. It usually begins with a chief complaint. The “history” includes a history of the present illness, past medical history, social history, and family medical history. Smoking can go under the heading of either Social History or Habits. There is usually a review of systems and a complete physical examination from head to toe. The report usually ends with an admission diagnosis and a plan for the patient’s treatment.
Consultation (Consult): This report is usually dictated by a physician to whom the admitting physician has referred the patient. Therefore, the consulting physician is usually a specialist in an area other than the admitting physician. Sometimes consultations are requested for second opinions. Consultation reports usually include a brief history of the patient’s illness and a specific physical exam depending on the particular type of consultation requested. The report may also include laboratory or x-ray findings. The report usually ends with the consulting physician’s impression and plan, and sometimes a comment from the consulting physician thanking the admitting physician for the referral.
Operative Report(OP): This report is dictated by the operating physician and contains detailed information regarding an operative procedure. Included in this report are preoperative and postoperative diagnoses, the type of surgery or surgeries that were performed, the names of the surgeon(s) and attending nursing staff, the type of anesthesia and the name of the anesthesiologist, and a detailed description of the operative procedure itself. Depending on the operative procedure, information regarding instrument counts, sponge counts and blood loss are also dictated. Often the report will end with disposition or where the patient was transferred when he left the operating room (usually recovery room) and the condition of the patient at the time of transfer.
Discharge Summary (DS): This report is dictated by the admitting physician at the end of the patient’s stay in the hospital. It includes a summary of everything that occurred from admission to discharge, including laboratory data, x-ray data, and pertinent physical findings throughout the hospital course. The report usually ends with the discharge diagnosis and a detailed plan for the patient. If the patient is transferred to another institution (such as a nursing or other hospital), the name of the report is usually changed from discharge summary to transfer summary. If the patient has expired (died) during the hospital stay, the report is usually called a death summary.
Radiology Report: This report is dictated by the radiologist upon completion of a diagnostic procedure and includes the radiologist’s findings and impression. Examples of radiology reports are x-rays, CT scans, MRI scans, nuclear medicine procedures and fluoroscopic studies.
Pathology Report: This report is dictated by a pathologist and describes findings of a tissue sample. The focus of the report is on the microscopic findings and the pathological diagnosis of the sample.
Laboratory Report: This report describes findings of examinations of bodily fluids such as blood levels and urinalysis. Laboratory reports are rarely dictated separately but are often included inside the H&P, consultation or discharge summary.
Miscellaneous Reports: Other miscellaneous hospital reports include cardiac catheterizations, electrophysiology studies, phacoemulsification, autopsies and psychological assessments.
You may be asking yourself what happens when a dictator makes an obvious grammatical mistake in his/her dictation. What do you do if a dictator makes an obvious mistake in subject/verb tense or even starts out talking about a male patient but later in the dictation says the word “female?” What do you do if a dictator is talking about a left leg injury but later says “right” leg? These are all good questions and the answer will be contingent upon whether you are working on a strictly verbatim account or one where you may light edit.
A verbatim account will require you to transcribe exactly what the doctor says regardless if it’s incorrect. An MT may not edit at all on a verbatim account. On the other hand, if you are working on an account and are allowed to edit lightly then you could fix the errors that were described in the above paragraph. The cardinal rule of light editing is to never change the meaning of the sentence. Below you will find an interesting article written by an experienced MT about verbatim vs’ light editing. Enjoy!
Verbatim = Using exactly the same words; word for word. No matter how stupid it sounds, no matter if they are an ESL (English as a second language) doctor with their sentences backwards, no matter if the sentence is three paragraphs long; you type it exactly the way it is dictated. Granted there are a few, and I do mean few, doctors that have an excellent command of English usage and know exactly where and what punctuation they want, but generally most dictators tend to string random thoughts and partial sentences into one long run on sentence.
You might ask yourself, why would anyone want their transcription to look that way? I’ve asked myself that same question many times. You will encounter verbatim typing almost anywhere, including services, clinics and hospitals. The question of “why” is somewhat of a mystery. Is it easier for the transcriptionist? The answer would be most assuredly it is. Who then has to take the ultimate responsibility for the sometimes incomprehensible dictation? The doctor signing their name at the bottom does. I’ve found over the years that this style of transcription leads to numerous edits. Once the doctors read over their dictation, that is IF they read over their dictation, they will inevitably want to change it, which, of course, leads to the transcriptionist having to spend twice as much time fixing it. This ultimately leads to longer turnaround times and frustration for the transcriptionist.
Thankfully, most of the places I have worked allow the transcriptionist to “light edit” or edit “on the fly,” versus full blown editing of the entire document using an English usage checker etc. Light editing is checking sentence structure and the proper use of tenses. Some of the other things you will be checking for include positions. For example, if the doctor is talking about a patient’s right arm and then starts saying left arm, the transcriptionist should be able to figure out which arm the doctor really means by what the rest of the dictation says. The same holds true for body parts, and this is where all that studying medical terminology comes into play. For example, if the patient is in for a foot problem and the doctor is talking about the patient’s metacarpals, you should know that the doctor means metatarsals. Another common error by dictators is the "he/she" error. They start off talking about “he” and wind up talking about “she.” Your job as a transcriptionist also includes catching these types of errors and correcting them.
You will find that after doing transcription for a while you will start to make these types of changes automatically or “on the fly” without having to read through your dictation to find the errors. I’m not saying you should not read through the document you just transcribed, but you will find yourself spotting and correcting these types of errors as they happen and proofing will become that much easier.
Comments
Post a Comment