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Administrative medical assisting 5th by lindh chapter16

Chapter 16

Medical Records

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Changing Role of
Medical Transcription
• Cost conscious
• Rapidly changing economy
• Impact of new technology

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Changing Role of
Medical Transcription
• Electronic medical records (EMR)

– May delegate much of MT’s responsibility to other
medical personnel
– Facilitate documentation and tracking of patient
care and outcomes
– Quick and easy access to accurate and readily
usable information

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Changing Role of
Medical Transcription
• Electronic medical records (EMR)
– All patient charts are scanned into EHR system
– Partial scanning of patient charts
– Do not scan any old information

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Changing Role of
Medical Transcription
• Outsourcing
– Contracting with a service outside of clinic or
hospital
– Task accomplished at lower cost, faster
turnaround time
– Advantages of outsourcing
– Important considerations before outsourcing
– Rapidly eliminating need for traditional
transcriptionist

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Changing Role of
Medical Transcription


• Voice recognition software (VRS)
– Converts voice to text using computer
– Specialized programs capable of translating highly
technical medical terminology
– Continuous speech technology

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Changing Role of
Medical Transcription
• Medical transcriptionist as editor





Quality assurance (QA) manager
Risk management
Editor or auditor
Flagging procedures

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Changing Role of
Medical Transcription
• Authentication
– Electronic signatures
• Alphanumeric computer key entries as identification
• Electronic writing device
• Biometric system

– Impact of Medicare and The Joint Commission on
electronic signatures

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Confidentiality and Legal Issues
• Differentiate between confidentiality and
privileged information
• Health Insurance Portability and
Accountability Act (HIPAA) Regulations

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Confidentiality and Legal Issues
• Protocols
– Procedures your office has in place to ensure
patient confidentiality
– Confidentiality agreement
– Documentation of compliance with HIPAA
– MT usually under jurisdiction of respondeat
superior

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Documents
• Documents part of patient’s permanent
medical record
• Vital to continued patient care
• May be reviewed by





Other providers
Attorneys
Insurance companies
Court

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Documents
• Medical report must be:
– Neat
– Accurate
– Complete

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Documents
• Common transcribed reports:






Chart notes and progress notes
History and physical examination reports
Radiology and imaging reports
Operative reports
Pathology reports

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Documents
• Common transcribed reports:





Consultations
Discharge summaries
Autopsy reports
Correspondence

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Turnaround Time and Productivity
• Hospital reports fall into four categories
– STAT reports: complete within 2 to 4 hours
– Current reports: complete within 24 hours or less
– Old reports or aged reports: complete within 48 to
72 hours or less
– TAT reports: when requesting copies of your
medical record usual TAT is 7 to 10 business days

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Medical Transcription as a Career
• Future of medical transcription is
changing
• Most health care providers use digital or
analog dictating equipment to transmit
dictation to medical transcriptionists

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Medical Transcription as a Career
• Medical transcription professionalism







Display a professional manner and image
Demonstrate initiative and responsibility
Work as a member of the health care team
Prioritize and perform multiple tasks
Adapt to change
Enhance skills through continuing education

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Medical Transcription as a Career
• Medical transcription professionalism
– Qualified MT: minimum of 2 years experience
performing medical transcription in variety of
medical and surgical specialties
– Certified medical transcriptionist (CMT)
– Registered medical transcriptionists (RMT)

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.



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