medical Transcriptionist - Creating a Streamlined and procure medical Documentation principles
The doctor or health specialist after diagnosing a inpatient dictates all the noted clinical observations into a recording device. The recorded narrative is transmitted over the internet, as a voice file to the curative transcription assistance provider. The transcriptionist attentively listens to the recorded voice and types the facts into the computer, to create an electronic file. This file after stringent capability operate checks is sent back to the physician, who market it in computer for time to come reference. While the transcription process, following equipments are used:
• A computer related to internet.
• A head set to listen to voice file.
• A foot pedal to pause the recording whenever necessary.
The curative transcriptionist transcribes variety of health reports and these include:
• Patient discharge reports.
• Medical history of patient
• Physical examination reports.
• Operative reports.
• Consultation reports.
• Autopsy reports.
• Diagnostic-imaging reports like radiology, Mri and ultrasound.
• Post operative improve reports.
• Referral letters.
It is important that transcriptionist must be trained in curative terminology and should have good knowledge of:
• Human anatomy and physiology.
• Medical diagnostic procedures.
• Pharmacology.
• Treatment assessments.
• Medical jargon and translate them into wide form.
• Standard reference handbook both in, electronic and printed version.
The curative transcriptionist should be skilled enough to spot mistakes or inconsistencies in the curative report. This saves the inpatient from receiving wrong medicine as a consequent of errors in the transcribed reports. Besides accuracy, the transcriptionist should to also have good speed to deliver back the transcribed narrative in a very short turnaround time. This helps involved doctor to deliver the necessary medicine to the inpatient in minimal time, thereby increasing the inpatient care. Ultimately the Hipaa compliancy norms make it mandatory for the covered entities like the hospitals, clinics and doctors to protect the privacy of inpatient health information. Hence it is moral duty of the transcriptionist to enounce the secrecy of the inpatient facts as per Hipaa norms.
A transcriptionist plays vital role in streamlining the curative documentation of hospital or healthcare clinic.
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