Dictation and Transcription Supported by Medical Documentation Specialists Can Improve the Accuracy of Your EMRPosted February 11, 2013 —
Electronic medical records (EMRs) have the potential to improve healthcare delivery by enabling patient information to be easily shared and accessed by physicians and other clinicians. However, physician entry of patient information without editing, whether dictated or typed, can result in errors that compromise the usefulness of EMR notes. Transcription medical documentation specialists enable physicians to concentrate on clinical activities, by assisting them with documentation tasks very similar to how nurses assist with patient care. These transcription medical documentation specialists serve as a second set of “eyes and ears” for physicians, and help to ensure the accuracy of clinical information in both paper charts and EMRs.
The most common critical errors were wrong patient, wrong drug name or dosage, and left/right discrepancy; the most common major error was use of made up words or acronyms. Even speech recognition is not immune to these errors. The most common critical speech recognition errors were wrong patient, wrong drug name or dosage, and wrong lab value. Again, the most common major errors were use of made up words or acronyms.
The accuracy of EMRs and even the paper-based medical records is improved when medical documentation specialists verify information dictated by physicians. Transcription documentation specialists edit reports as part of their job, correcting obvious errors and flagging others for physician clarification. Dictation is the preferred method of documentation for most physicians because it aids clinical decision making, makes efficient use of physicians’ time, and produces narrative notes ideal for sharing with other clinicians.
But, just as important, adding dictation to your EMR, supported by transcription medical documentation specialists will increase the accuracy and safety of the care you provide.