A report published by New England Medical Transcription (NEMT) addresses a presentation at HIMSS that’s all about transcriptionists. The report explains more about the arguments in Rise of the Field of Medical Transcriptionists – Dangers to EHR Advancement offered by S. Luke Webster, MD and George Gellert, MD.
It relays, “The presentation showed its concern regarding unlicensed individuals who submit patient data such as CPOE into the EHR. They’re being put in certain situations where they need to make choices for which they haven’t been trained.”
A transcriptionist works hand-in-hand with the care provider when it comes to documentation the electronic healthcare record (the EHR). A transcriptionist isn’t present physically throughout the provider/patient meeting. Transcriptionists are specifically qualified to interpret and submit expected aspects of documentation in order for the providers to receive the highest compensation for their service.
Entering Current Conditions: After the patient is done talking to the doctor, the transcriptionist records the knowledge given by the patient. The transcriptionist doesn’t deliver any decisions themselves in this segment (typically narrative). The transcriptionist is equipped to transpose “patient speak” to a precise medical style.
Let’s say a patient laments that she’s been having a “stomach ache for a week—It’s a stomach sickness that’s making me throw up constantly.” The transcription may enter, “The female patient is presenting a week of abdominal pain to the ED today. She says she’s experienced nausea and is vomiting repeatedly.” No independent analyses or judgments are provided here. The transcriptionist may put the information in quotation marks if it’s not enough to be translated or is asserted best as a quote.
What transcriptionists do not do: Perform independent assessments or decisions about a patient’s treatment or care; diagnose; determine orders such as medications and/or labs; alter the patient’s words to change the meaning or context completely; assist or handle any procedures, even the most innocuous.
Hiring a high-quality medical transcriptionist through us at 360 Transcription can eradicate most of the mistakes you can experience with amateur transcriptionists. We’d love to explain how we can help your facilities run more smoothly, so don’t hesitate to call us at 1.877.360.TRAN (8726) for a quote today!