Medical Transcription Outsourcing – Fulfilling The Purpose Of Clinical Documentation

The process of healthcare is based on the premise of drawing meaningful and significant inputs from various sources, including the experience, education and expertise of healthcare professionals & support staff, inputs from other sources like pharmaceuticals, laboratories and numerous other sources. Information regarding every step of the healthcare process in a patient medical record is one factor that has always been a common factor helping bring together all sources to provide quality healthcare profitably.

Medical transcription is the process of creating patient medical records from the dictation of the patient- healthcare professional encounter. Accurate, timely and secure creation of patient medical records is the result of the culmination of resources like the right team, the right processes and the right technology. Outsourcing medical transcription ensures that patient medical records meet all the quality criteria without diluting the focus of healthcare facilities on their core business of providing quality care and also ensures enormous cost saving benefits.

Outsourced service providers help the healthcare facility fulfill the purpose of clinical documentation.

How do outsourced services help fulfill the purpose of clinical documentation?

The purpose of documenting the patient- healthcare professional encounter can be defined as:

  • To provide a point of reference:Patient medical records basically provide a chronicle of the patient’s health history. This information is invaluable as a diagnostic tool for planning present and future care
  • For the purpose of communication: The process of healthcare requires that a primary healthcare professional may refer to specialists for inputs regarding the treatment provided to the patient. Patient medical records are essential for communication in such cases.
  • To establish accountability: Patient medical records act as evidence of the appropriateness of care provided. These inputs are invaluable in case of litigation where the healthcare professional has to justify the diagnosis and the treatment provided.
  • Fulfill legislative requirements: Maintaining patient medical records for a certain period of time is mandated by law.
  • Quality improvement:Documenting the healthcare process helps healthcare professionals and healthcare facilities improve the quality of healthcare services provided.
  • Research: Patient medical records provide valuable inputs for research and also help healthcare facilities provide preventive care
  • To ensure reimbursements:Patient medical records are the basis on which coding and billing is done leading to reimbursements.

Outsourced medical transcription services help in all the mentioned aspects of documentation by providing services with the following benefits:

Accurate: It is ensured that the transcripts are created with maximum accuracy using specialty trained transcriptionists and stringent quality check methods

Timely:It is ensured that transcripts are made available to healthcare facilities and healthcare professionals using a combination of the right team and the right technology

Secure:It is ensured that the confidential patient data is secure throughout the medical transcription process by securing technology, teams and infrastructure

Cost effective: Outsourced vendors are able to help healthcare facilities and healthcare professionals save on cost of transcription substantially by helping them convert fixed cost of transcription to variable costs, bring down the cost of transcription by passing on the benefits of economies of scale achieved by them and eliminating indirect costs.

Technology:Transcription providers have used technology to provide services with the following benefits, while still being easy to use:

  • Retaining familiar modes of dictation
  • Different modes of document delivery
  • Archives
  • EMR/EHR adoption

It can be seen that outsourced medical transcription service providers understand the need for clinical documentation and help fulfill the purpose of documentation.