Administrative medical assisting 5th by lindh chapter16

Chapter 16 Medical Records © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part The Changing Role of Medical Transcription • Cost conscious • Rapidly changing economy Impact of new technology â 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part The Changing Role of Medical Transcription • Electronic medical records (EMR) – May delegate much of MT’s responsibility to other medical personnel – Facilitate documentation and tracking of patient care and outcomes – Quick and easy access to accurate and readily usable information © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part The Changing Role of Medical Transcription • Electronic medical records (EMR) – All patient charts are scanned into EHR system – Partial scanning of patient charts – Do not scan any old information © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part The Changing Role of Medical Transcription • Outsourcing – Contracting with a service outside of clinic or hospital – Task accomplished at lower cost, faster turnaround time – Advantages of outsourcing – Important considerations before outsourcing – Rapidly eliminating need for traditional transcriptionist © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part The Changing Role of Medical Transcription • Voice recognition software (VRS) – Converts voice to text using computer – Specialized programs capable of translating highly technical medical terminology – Continuous speech technology © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part The Changing Role of Medical Transcription • Medical transcriptionist as editor – – – – Quality assurance (QA) manager Risk management Editor or auditor Flagging procedures © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part The Changing Role of Medical Transcription • Authentication – Electronic signatures • Alphanumeric computer key entries as identification • Electronic writing device • Biometric system – Impact of Medicare and The Joint Commission on electronic signatures © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Confidentiality and Legal Issues • Differentiate between confidentiality and privileged information • Health Insurance Portability and Accountability Act (HIPAA) Regulations © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Confidentiality and Legal Issues • Protocols – Procedures your office has in place to ensure patient confidentiality – Confidentiality agreement – Documentation of compliance with HIPAA – MT usually under jurisdiction of respondeat superior © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Types of Medical Documents • Documents part of patient’s permanent medical record • Vital to continued patient care • May be reviewed by – – – – Other providers Attorneys Insurance companies Court © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Types of Medical Documents • Medical report must be: – Neat – Accurate – Complete © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Types of Medical Documents • Common transcribed reports: – – – – – Chart notes and progress notes History and physical examination reports Radiology and imaging reports Operative reports Pathology reports © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Types of Medical Documents • Common transcribed reports: – – – – Consultations Discharge summaries Autopsy reports Correspondence © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Turnaround Time and Productivity • Hospital reports fall into four categories – STAT reports: complete within to hours – Current reports: complete within 24 hours or less – Old reports or aged reports: complete within 48 to 72 hours or less – TAT reports: when requesting copies of your medical record usual TAT is to 10 business days © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Medical Transcription as a Career • Future of medical transcription is changing • Most health care providers use digital or analog dictating equipment to transmit dictation to medical transcriptionists © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Medical Transcription as a Career • Medical transcription professionalism – – – – – – Display a professional manner and image Demonstrate initiative and responsibility Work as a member of the health care team Prioritize and perform multiple tasks Adapt to change Enhance skills through continuing education © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part Medical Transcription as a Career • Medical transcription professionalism – Qualified MT: minimum of years experience performing medical transcription in variety of medical and surgical specialties – Certified medical transcriptionist (CMT) – Registered medical transcriptionists (RMT) © 2014 Cengage Learning All Rights Reserved May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part  ... whole or in part Medical Transcription as a Career • Medical transcription professionalism – Qualified MT: minimum of years experience performing medical transcription in variety of medical and surgical... website, in whole or in part Types of Medical Documents • Documents part of patient’s permanent medical record • Vital to continued patient care • May be reviewed by – – – – Other providers Attorneys... in part Medical Transcription as a Career • Future of medical transcription is changing • Most health care providers use digital or analog dictating equipment to transmit dictation to medical