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Medical Dictation Service: How to create Quality Patient Health Records

Comprehensive and meticulous documentation of the process of health care has always played a crucial role in the medical service environment. Medical information that is extracted from provider-patient encounter is seen to have vital implications on different aspects of care delivery, namely, Claims and billing purpose, patient safety, and continuity and coordination of care.

Now that worldwide it has been made mandatory to create and manage digital medical records system, the type of documenting the health care processes has gained attention. Medical Transcription is an old method for care process documentation that is vital in assuring comprehensive, useful, and accurate documentation.

By evaluating the alternative techniques of medical documentation, it becomes possible to justify the importance of medical dictation services and adoption of Electronic Medical Records. A few of such alternative methods have been listed below:

  • Speech Recognition Software
  1. One of the primary solutions helping in prompt documentation of medical care encounters, Speech Recognition Software provides the advantage of reduced Turnaround time. On the negative side, accuracy of information that is captured may not be reliable, necessitating proofreading and editing services for those transcripts which have been produced through Speech Recognition Software. These additional processes, although involving expenditure, ensure that patient health records consist of complete and accurate information.
  • Templated Documentation Type
  1. Applying drop down style menus or templated way of documentation enables real-time functioning of health care process. This method requires quality checks and focused performance from the end of medical professionals.
  • Use of Scribes
  1. This is another method of documenting health care process documentation. This has a few shortcomings as listed below:
  2. Lack of clarity
  3. Concerns over security & privacy
  4. Errors in formatting
  5. Negligence in medical terminology

By availing medical transcription service from a reliable and skilled team of transcriptionists with experience and required technology, medical practices and clinicians may be able to gain time and resources for better engaging themselves.