National Medical Transcription Week: It’s time we thank the guardians of health record integrity

This week is National Medical Transcription Week, and I would like to thank all of the hardworking medical transcriptionists and other healthcare documentation specialists (HDS) who support physicians every day in creating complete, accurate, and high quality patient care documentation. This year’s theme is “Guardians of Health Record Integrity;” so I would like to highlight a very important but often overlooked part of the healthcare documentation process, quality assessment (QA).

Within the healthcare documentation process, there are three different workflows for QA:

Flagged concurrent review As healthcare documentation specialists (HDS) complete each job, they may encounter blanks, inconsistencies, or other questionable content that they are unable to resolve even after extensive research. Because guessing is never acceptable in healthcare documentation, the HDS flags the document so that it will be routed to a QA reviewer for further scrutiny. The QA reviewer will attempt to resolve the flagged issues and then send the document on to the dictator for authentication. Flagged concurrent review ensures that the healthcare documentation team has done its due diligence in creating a complete and accurate document within the context of the patient’s situation before it is returned to the dictator. However, sometimes issues in the dictation have to be resolved by the dictator before signature.

Sampled concurrent review When an HDS is new or inexperienced with an account, specialty, dictator, or work type, her employer will likely send a certain percentage or number of her documents to QA for review (and feedback, if necessary) before they are authenticated and distributed. In many cases, the employer will review 100% of the documents in a specific category for a new HDS until they are confident that the HDS has the knowledge and skills to process those jobs without assistance. Often the sampling rate will be reduced incrementally as quality goals are met to coincide with departmental guidelines. Some organizations also use sampled concurrent review to monitor individuals who are on a performance review plan and need more oversight. This form of QA enables clear, consistent, real-time feedback intended to increase the knowledge and improve the accuracy of the HDS.

Retrospective review A seasoned HDS has typically earned the employer’s trust and does not require sampled concurrent reviews, but sometimes a random sample of previously completed work is reviewed in order to ensure that the expected level of quality is being maintained. Retrospective review occurs outside of the real-time document creation workflow, so it does not affect established turnaround times like concurrent review can. However, because the documents being reviewed have already been authenticated by the dictator and distributed, it is important to conduct retrospective reviews before audio files are purged so that the content of the document can be compared to the original dictation. Some organizations use retrospective review as part of an HDS’s annual performance review. Others use retrospective sampling to look at quality for specific account, specialty, dictator, or work type and determine if improvements could be made to tools and processes that would prevent recurring problems.

All three forms of QA workflow are essential to ensuring that each patient’s narrative is as clear, consistent, accurate, complete, timely, and compliant as possible. This week, be sure to show your appreciation to the medical transcriptionists, QA reviewers, and other healthcare documentation specialists in your organization who are so passionate about the details of every patient’s story. Their behind-the-scenes efforts protect patients, physicians, and the healthcare organizations that they serve every day.

Jill Devrick is the AHDI President and a Product Solutions Advisor with 3M Health Information Systems.

4 responses to “National Medical Transcription Week: It’s time we thank the guardians of health record integrity

  1. Being an MT is no longer a profession that pays a living wage in the US in part due to ADHI. If you want to make $9-$10 an hour working for a service/sweatshop be my guest. A few hospitals have seen how bad the stuff is from the services and hired their own staff with a better pay scale and benefits but that is not the norm. This article makes out like everything is just wonderful, but just ask all the people who had to get out when they couldn’t pay the bills anymore how they feel about it.

  2. You have obviously had a bad experience as an MT. I am sorry that you have a negative view of the medical transcription sector, although I can understand why. While I admit that the past several years have been challenging for medical transcription, I believe that the services of MTs and other healthcare documentation specialists are going to continue to be a necessary function to promote documentation quality and patient safety.

    MTs are often put in situations in which they are treated as production-based data entry workers and not skilled knowledge workers because the workforce, and hence the healthcare industry, does not universally embrace a standard for individual knowledge and skills for MTs as almost all other healthcare professions do. However, I know hundreds of MTs who are choosing to view the challenges brought on by technology, regulations, and other practices as opportunities to showcase our expertise through certification programs and development of best practices that will reinforce the importance of documentation quality to patient safety.

    I am starting to see medical transcription departments broadening their scope to “documentation integrity services” as they continue offering transcription and editing services but also take on new QA and EHR support roles. And some MTSOs are broadening their service offerings to meet the needs of their healthcare clients. As the healthcare industry continues to be impacted by ICD-10, EHR adoption, meaningful use guidelines, and more over the next several years, it is important that MTs assert themselves in conversations about documentation quality until it becomes a strategic priority and a highly valued skill-set.

  3. I agree, Jill. I think this article supports that Healthcare Documentation Specialists and Medical Transcriptionists are not just typing blindly; but that there is a knowledge and skill as well as a quality process that goes into producing the health record. All of which cannot be accomplished by speech recognition and EMR/EHR once and done concept alone. Although there have been some diminishing of wages and respect in the medical transcription industry, there has also been a broadening of opportunity and skillsets; and quite frankly, I think, a realization that this important element is necessary. I appreciate this reminder that in the end “quality” is most important and that should be recognized.

  4. I agree Linda Giles.. The medical transcriptionists are doing a great job and i really respect the medical transcriptionists as well as the medical transcription industry.

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