Medical transcriptions

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  • 1. Written by:Jim PlewaChief OperatingOfficerCaseReader by DPR

2. Medical TranscriptionsMedical transcription is theart (and science) ofcapturing physiciansdictated words in a reportaccurately, an increasinglyimportant task whenconsidering the growth ofelectronic health recordsacross all medical practicesin recent years.by: Jim Plewa, Chief Operating Officer of CaseReader 2 3. Medical TranscriptionsThe production of medicaltranscripts is a time-consuming task butaccuracy in a patientshistory is paramount,especially when moremedical professionalsacross a variety ofspecialties will access thesame report during theirinteractions with apatient.by: Jim Plewa, Chief Operating Officer ofCaseReader 3 4. Medical TranscriptionsNo longer are medical records simply tied to a single practice and,therefore, medical transcription services are increasinglyoverwhelmed with requests for clear and accurate medicaltranscript production.by: Jim Plewa, Chief Operating Officer of CaseReader 4Many practices outsource thiswork to those trained asmedical language experts butthis field of medicaladministration is also thefocus of innovative voicerecognition technology to aidin producing these medicaltranscripts. 5. Medical TranscriptionsA patients medical transcript will contain a wealth of information,including their symptoms, medical history, family history, testresults, details of prescriptions and procedures and a diagnosis.by: Jim Plewa, Chief Operating Officer of CaseReader 5Whenever a patient visitstheir physician andundergoes anexamination or spendstime talking through theirsymptoms and/orprogress the physicianwill make a record of theoutcome of the visit. 6. Medical TranscriptionsOftentimes, a physician uses ahandheld voice recorder todictate notes after thepatient has left and thesewill be then be passed on toa medical transcriptionist.by: Jim Plewa, Chief Operating Officer ofCaseReader 6 7. Medical TranscriptionsProducing a medical transcript is not as simple as typingout the words spoken by the physician as a patients reportis considered a legal document and requires specificformatting.Once the transcript is complete it is entered into thepatients file and can be called on in the future by thephysician themselves or by another specialist treating thepatient.by: Jim Plewa, Chief Operating Officer ofCaseReader 7 8. Medical TranscriptionsThe correct formatting, review and editing of a medicaltranscript is important as this not only makes it muchfaster for physicians reviewing the patients history, it alsomeans that an improperly recorded medication isidentified quickly and can be corrected to avert risk.The physician providing the dictated notes is supposed toreview the transcript upon completion but, in practice,some physicians do not review these transcripts and theyare marked instead as dictated but not read to signalthat there may still be potential accuracy issues.by: Jim Plewa, Chief Operating Officer of CaseReader 8 9. Medical TranscriptionsMedical transcribers can also flag a transcript if they spotinconsistencies in the report or if the words captured bythe recorder were unrecognizable.Slow, precise and concise speech is vital to helping atranscriber produce accurate work and the same is true forvoice recognition technology when dictating the names ofmedications, the procedure undertaken and the diagnosis.by: Jim Plewa, Chief Operating Officer ofCaseReader 9 10. Medical TranscriptionsMedical transcribers have tocontend with regional and evennational accents, rushed speech(particularly from EmergencyDepartment physiciansphysician), mispronunciationsand abbreviations of medicalterminology, disordered speechwhen a physician recallssomething out of the context ofthe current sentence, and evenincorrect dosages or other errors.by: Jim Plewa, Chief Operating Officer ofCaseReader 10 11. Medical TranscriptionsThe transcriber must also make sure to check referencesand the proper spelling of medical terminology andhighlight any problems they see in the report for thephysicians review. Medical transcriptionists need toconstantly be updating their database of new medicalequipment, drugs, devices and nomenclature in order toproduce accurate reports and this is just one area where acentralized database available with voice recognitionsoftware is helpful.by: Jim Plewa, Chief Operating Officer ofCaseReader 11 12. Medical TranscriptionsPhysicians looking forefficiencies can alsoimprove the accuracy oftheir own dictation,produce clearer medicaltranscripts that areproperly formatted andeasy to review whilereducing wait-times foroutsourced medicaltranscription services byusing medical speech-to-text voice recognitiontechnology such asM*Modal Fluency.by: Jim Plewa, Chief Operating Officer ofCaseReader 12 13. Medical TranscriptionsOne solution CaseReader by DPRhas embedded M*Modal voicerecognition technology.Within CaseReader Fluency isutilized for navigation and dictationin a templated environment toproduce timely and accurate clinicaldocumentation.by: Jim Plewa, Chief Operating Officer ofCaseReader 13 14. Medical TranscriptionsThe all-software solution enhancesproductivity and may increaserevenue by ensuring accuracy andsafety in patients medicaltranscripts.Its seamless integration with theability to embedded images in thefinal report make CaseReader avaluable tool for radiologists andreferring physicians.by: Jim Plewa, Chief Operating Officer ofCaseReader 14 15. 2400 Camino Ramon, Suite 125,San Ramon, CA 94583925-327-0835 | info@casereader.comwww.casereader.comConnect with CaseReader on:http://www.facebook.com/CaseReaderMedical TranscriptionsWritten by:Jim PlewaChief Operating OfficerCaseReaderConnect with Jim on:http://www.linkedin.com/in/jimplewahttps://twitter.com/Jim_Plewa