Medical Transcription Outsourcing – Providing Support for Medico Legal Documentation Needs

Medical transcription has been providing valuable support to the healthcare sector by faithfully documenting the patient- healthcare professional encounter in its entirety. This process becomes even more efficient and economic by outsourcing. Outsourced services are able to meet all the required standards like accuracy, turnaround time, security and being cost effective as creating patient medical records is the core business of the service provider and all the resources of the service provider are focused towards providing quality services.

Another aspect that these services aid in, is the medico-legal aspects of healthcare facilities by creating comprehensive and accurate patient records. In an increasing litigious environment complete patient records are vital as evidence in case of malpractice suits.

This helps in medico-legal aspects by

Properly recording and documenting patient’s current and past medical history

Helping document the rationale surrounding the medical reasonableness of the treatment

Documenting necessity of all patient diagnostic testing administered

Providing sufficient basis to reconstruct, fully justify and explain the facts and circumstances giving rise to the patients’ condition and course of treatment

Ensuring that the patient case history contained in the clinic file for the patient will become the center piece of any litigation and/or claims negotiations regarding the reasonableness and necessity of the treatment and diagnostic testing by capturing all the details completely and accurately.

Documentation usually reflects a course of treatment; increased emphasis on proper documentation provides proper safeguards against malpractice claims. Proper documentation of the patient- healthcare professional encounter has the following advantages:

Increase the quality of patient care by recognizing accelerated or prolonged symptoms leading to further investigation

Provides justification for patient care, by reflecting detail and capturing objective physical examination findings that support the course of treatment. This aspect of documentation also helps in claiming payments

Proper documentation helps in increasing referrals to the healthcare professional by reflecting on his/ her ability to provide quality care

Protection against litigation.

It can be seen that outsourcing to a transcription vendor who believes that maintaining quality and security of documentation as their priority helps the healthcare facility in many ways.

To ensure quality documentation of the patient- healthcare professional encounter, the medical transcription service provider needs to be assessed on criteria like:

Accuracy: The acceptable level of accuracy versus what was dictated has to be 98% and above

Turnaround time: Turnaround time is the time taken to deliver the finished transcripts to the healthcare professional. This needs to be customized to the specific requirements of the doctors and other personnel at the facility.

Data security: The process of medicine is based on the comfort level of the patient and his/ her belief in the ability of the hospital/ doctor to protect the confidential information provided by them. The vendor creating patient medical records needs to be HIPAA and HITECH compliant.

Pricing: One of the main benefits of availing specialized services from an outside source is to save on costs both direct and indirect.

Technology: The technology used by the medical transcription service provider should not only secure but should also be easy to use, without having to require extensive training

As documentation of patient- healthcare professional is vital for protection in the medico-legal aspects, choosing the right service provider is vital.