Do you know that only a good dictation can result in a good documentation or transcription? Just think of the possible impacts on a patient’s health if a medical transcriber wrongly documented after a wrong dictation. Since documentations are medical related, it should have high quality. Some factors like medical billing and coding, potential audits backups also influence the ethics of clinical reporting.
Here are some main tips that will help you in availing accurate results from your Medical Transcription Service Provider.
- Clear tone
While you are dictating, the first thing to understand is that, your patient will be the sufferer unless you speak clearly. The quality of the documentation matters rather than fast dictation.
- Hold the mic properly
Holding the mic in one direction and not speaking exactly to the mic will not result in a good documentation. Thus holding it and speaking to it is a must. The sound should not go directly into the mic instead it should go over the mic. For this, keep a distance of ¾ inch from the mouth.
- Dictate from a calm and quiet place
As I mentioned earlier, the transcriber will document only the report which you have dictated. So its your keen responsibility to dictate an error free, high quality audio which is to be transcribed. For this to attain, avoid environments that are noise polluted.
- Prompt dictation–Happy patient
Always keep in mind that the immediate time after consulting a patient is the best time to record the audio files that should be transcribed by the Medical Transcription Company.
- Handling tough words
If there are certain difficult words like referring other physician’s name, drugs, alike sounds, numerical descriptions and units of measure, just have a double attention in speaking out. Even though, the Medical Transcription Service Provider uses Steadman’s Medical Dictionary for referring the spellings and other checks, it’s the dictators duty to give a clear dictation.
- Creating a new audio file
At a later stage, if you want to add some points to the documentation or you want to change some of the notes in the documentation, create a new audio file stating about the amendment and the patient’s name to avoid confusions.
- Encoded Files
Please make sure that you won’t send the audio files through emails. It should be sent to your Medical Transcription Company by following MTSO’s protocol, while sending audio files. MTSO provides software like ZyDoc’s “ZyFile” for lengthier transcription.
- Medical Transcription Service Provider
Even if you have sent an audio file with high quality, the transcription service provider should have keen knowledge of medical terms. So always be alert while you are selecting a best Medical Transcription Company. To select the best company give a sample test to check the documentation works and decide based on the performance.
- Quality assurance
Seek your transcription service providers Quality assurance department and works before documentation. A full time dedicated provider will have separate columns for major and minor errors. According to the Association for Healthcare Documentation Integrity (AHDI), “critical errors are those which could compromise patient safety or continuity of care. Major errors are those which could compromise the integrity of a note without risk to patient care.”
- Give feedback
Provide feedback to transcriptionist and prompt them if there is any changes to be carried out in the documentation they prepared.
To conclude, good dictation is the key factor for good transcription, but it’s not the only factor. There are many factors like work habits, providing correct information, reporting about amendments, secured file transmission that influence a will lead to a smooth documentation.