A CASE FOR MEDICAL TRANSCRIPTION USE By Victor Wanyama
Over the years, medical transcription has become an integral part of the healthcare profession. It largely involves the transcription of voice recordings and notes taken down by nurses, physicians as well as other healthcare professionals. The content of these recordings and notes varies according to the nature of work that the professional is performing. It can include anything from class lecture notes to patient records.
The process of transcribing medical records has existed from as far back as the 20th century since it became increasingly important to have records that could be used as a reference point in teaching and learning of techniques that were practiced in the past. Before medical transcription was considered an individual career option, medical practitioners would often work in conjunction with stenographers whose main work was taking the information dictated by the practitioner in shorthand. However, as technology continually advanced, more efficient tools were invented to aid in the collection of data. Audio recorders gradually found their way into hospitals and would be used by the medical practitioners to capture their dictations which they would then transcribe later on. Technological evolution cut across all the aspects of transcription with the documents being written using typewriters as opposed to manually being written using pen and paper. However, the inventions did not stop there, and soon enough; the typewriters were being replaced by computers utilizing word processing applications as well as digital storage.
Medical reports are highly detailed documents containing vital patient information that can be used for future reference. Due to the level of detail, these reports are often made up of a compilation of handwritten notes made by the doctor as well as typed reports concerning the patient’s medical history which are then all compiled to form a single document. In a hospital setting that handles dozens of patients daily, the storage of these records soon becomes a huge problem as the storage locations quickly get filled up. The process of retrieval of these documents also becomes quite an arduous task as one has to comb through a huge number of files to get to their desired file. To try and combat this challenge, medical reports were often duplicated using carbon copies to ease their retrieval when needed. This still brought the issue of excess clutter as the paperwork would quickly fill the filing cabinets.
The introduction of computers to medical transcription meant that filing cabinets could now be replaced with digital storage locations such as hard drives and file servers. The adoption of file servers ensures that retrieval of data is made possible remotely granted the person seeking the information has the relevant credentials. It also avails specific information that is relevant to a particular scenario since computers can filter out information based on specified criteria.
The development of medical transcription has been further enhanced by the use of computers since transcribers can now make use of speech recognition software to capture the information recorded on audio devices. This is however not without its fair share of issues since factors such as accent and tonal variation play a huge role in the accuracy of the data. The medical transcribers have to, therefore, act as editors to ensure the information captured is accurate. The importance of having the information captured accurately cannot be understated as it usually is the difference between a patient receiving proper treatment and missing it. A patient’s report usually has complete details of the procedures that were performed on them stated by the medical practitioner. It is from this oral dictation that a medical transcriber’s job begins.
The medical transcriber’s job does not simply end with typing everything they capture from the medical practitioner’s recordings. They have to filter out the most important bits of the information then arrange it systematically to create a logical flow which will then be used to create a medical history report of a patient. This is essential since medical practitioners usually have very busy schedules and it would be next to impossible to peruse through the entire patient history to get to the section that concerns them.
BENEFITS OF MEDICAL TRANSCRIPTION TO HEALTHCARE PRACTITIONERS
With the introduction of medical transcription to healthcare facilities, major improvements have been observed in the service delivery of healthcare practitioners. This is in part because the practitioners do not have to use up time that would be otherwise used in the treatment of patients in transcribing their work. Before medical transcribers were integrated into hospital systems, the healthcare practitioners would be forced to take down notes of the activities they carried out on a particular day before clocking out of their shift. This activity alone could consume more than an hour; time which could be spent in treating patients. Currently, medical transcribers only need the voice recording of the medical practitioners for them to create patient reports. By creating these medical reports, medical transcribers help medical practitioners communicate with each other effectively without the need to meet face to face. This is because all the information that a practitioner may require before effecting treatment is contained in these medical reports. Healthcare practitioners are also able to have an in-depth study of various reports and learn from them. A vast majority of hospitals have turned to digital reports as their go-to mode of storage since the reports can be easily accessed by doctors, edited as well as filtered to display the information that they require almost instantly.
BENEFITS OF MEDICAL TRANSCRIPTION TO PATIENTS
Medical transcription has brought about significant improvements to the healthcare that patients receive in health facilities. This is due to the increased amount of patient information that is collected to aid in the diagnosis and treatment of illnesses. With medical transcriptions, doctors can effectively communicate patient medical history, the treatment they have received as well as any other issues that may arise during the process of treatment. Equipped with this information, medical practitioners can make a sound judgment on the course of action to be taken on each patient. Medical transcripts are also available for patients to go through to fully understand their condition. This is a sharp contrast to the period before the advent of medical transcriptions whereby information was hard to come by. Since this information can be shared over the internet, patients are also able to seek further treatment abroad without much struggle. The foreign doctor simply needs to request a copy of the patient’s medical history report from his/her previous hospital to gain an understanding of the measures to take. Medical transcription has also ensured that patients receive quality healthcare since all the activities of the medical practitioners are recorded. These records can be used by patients who feel that they did not receive the best possible care to lodge complaints against the health practitioners and the hospital at large.
IMPACT OF MEDICAL TRANSCRIPTION IN KENYA AND AROUND THE WORLD
The field of medical transcription is on a constant growth trajectory. This means that new ways of doing transcription are coming up with each passing day. This growth has brought about the development of transcription firms whose main focus is carrying out medical transcription on behalf of hospitals. Transcription is a very delicate activity and requires a full understanding of the topic before commencing the work. In the medical field, it is even more important since a slight misspelling or mistyping can result in a different outcome. The process of recruiting professional medical transcribers can prove to be quite challenging especially since most general transcribers do not have a medical background and therefore find it difficult to deal with medical jargon. This situation has seen most hospitals having to contend with under-qualified transcribers which in turn leads to poor quality reports despite getting good quality recordings from the medical practitioners.
To conquer this challenge, hospitals are turning to professional medical transcription service providers to create their medical reports. These transcription service providers guarantee more confidentiality between the doctor and the patient since the transcriber does not have to be physically present to transcribe the information. Instead, they rely on voice recordings made by doctors. This sees the patients being more comfortable hence giving more accurate information. Since these transcribers do not have to be physically present at the hospital, they can work from anywhere with a computer and internet connectivity. This also brings down the cost incurred by the hospitals significantly since they no longer require permanent and pensionable transcribers.
In Kenya and the world at large, medical transcription has drastically improved the quality of healthcare that patients receive since medical practitioners can now fully focus on their practice and not have to worry about the information being captured since the process is being conducted by professionals. By also avoiding burnout, the practitioners are more effective in their workplaces thus reflecting on the quality of work they do. Lastly, the process of storing and retrieving patient records has been greatly improved since records stored digitally can be easily accounted for in case of need by other medical practitioners or to seek insurance claims.