Medical Transcriptions

Medical transcription is the art (and science) of capturing  physicians’ dictated words in a report accurately, an increasingly important task when considering the growth of electronic health records across all medical practices in recent years. The production of medical transcripts is a time-consuming task but accuracy in a patient’s history is paramount, especially when more medical professionals across a variety of specialties will access the same report during their interactions with a patient. No longer are medical records simply tied to a single practice and, therefore, medical transcription services are increasingly overwhelmed with requests for clear and accurate medical transcript production. Many practices outsource this work to those trained as medical language experts but this field of medical administration is also the focus of innovative  voice recognition technology to aid in producing these medical transcripts.

A patient’s medical transcript will contain a wealth of information, including their symptoms, medical history, family history, test results, details of prescriptions and procedures and a diagnosis.   Whenever a patient visits their physician and undergoes an examination or spends time talking through their symptoms and/or progress the physician will make a record of the outcome of the visit. Oftentimes, a physician uses a handheld voice recorder to dictate notes after the patient has left and these will be then be passed on to a medical transcriptionist. Producing a medical transcript is not as simple as typing out the words spoken by the physician as a patient’s report is considered a legal document and requires specific formatting. Once the transcript is complete it is entered into the patient’s file and can be called on in the future by the physician themselves or by another specialist treating the patient.

The correct formatting, review and editing of a medical transcript is important as this not only makes it much faster for physicians reviewing  the patient’s history, it also means that an improperly  recorded medication  is identified  quickly and can be corrected to avert risk. The physician providing the dictated notes is supposed to review the transcript upon completion but, in practice, some  physicians do not review these transcripts and they are marked instead as “dictated but not read” to signal that there may still be potential accuracy issues. Medical transcribers can also flag a transcript if they spot inconsistencies in the report or if the words captured by the  recorder were unrecognizable.  Slow, precise and concise speech is vital to helping a transcriber produce accurate work and the same is true for voice recognition technology when dictating the names of medications, the procedure undertaken and the diagnosis.

Medical transcribers have to contend with regional and even national accents, rushed speech (particularly from Emergency Department physicians physician), mispronunciations and abbreviations of medical terminology, disordered speech when a physician recalls something out of the context of the current sentence, and even  incorrect dosages or other errors.  The transcriber must also make sure to check references and the proper spelling of medical terminology and highlight any problems they see in the report for the physicians  review. Medical transcriptionists need to constantly be updating their database of new medical equipment, drugs, devices and nomenclature in order to produce accurate reports and this is just one area where a centralized database  available with voice recognition software is helpful.

Physicians looking for efficiencies can also improve the accuracy of their own dictation, produce clearer medical transcripts that are properly formatted and easy  to review while reducing wait-times for outsourced medical transcription services by using medical speech-to-text voice recognition technology such as M*Modal Fluency. One solution CaseReader™ by DPR has embedded M*Modal voice recognition technology.  Within CaseReader™ Fluency is utilized for navigation and dictation in a templated environment to produce timely and accurate clinical documentation. The all-software solution  enhances productivity and may increase revenue by ensuring accuracy and safety in patients’ medical transcripts.   Its seamless integration with the ability to embedded images in the final report  make CaseReader™ a valuable tool for radiologists and referring  physicians.