Module 08 MT Project
Module08 MT Project
QualityPolicy for Medical Transcription Department
Themost important facet of quality management in the medical fieldinvolved documentation of patient records and other records in ahealthy care facility. Proper management of the facility records hasan important impact on other aspects of the facility operations,including the quality of services offered. Additionally, qualitymanagement of healthy records is a statutory requirement in manycountries. There are certain norms and guidelines that must befollowed when dealing with medical records. These guidelines aredevelopment by the relevant statutory regulators, professionalorganizations or at the medical institution level. These guidelinesform the basis of quality policies in the management of medicalrecords. Medical transcription department is one of the most criticaldepartments in the management of medical record. Medicaltranscription refers to the process of converting dictation or voicemedical report into a text format. The medical transcriptiondepartment is tasked with recording and editing doctors’ reports,notes and procedures in an electronic text format. The text formatenables the facility to create files and medical records thatrepresent the history of each of the clients visiting the facility.Usually, the doctors dictate the procedures performed on the patientafter treatment, which is captured and converted into a text reportfor filling (Lindh, 2013).
Theachievement of high quality standards in medical transcription is notpainless or simple. Medical facilities require a well defined and allinclusive quality policy that will guide the transcription teamtowards achieving the highest quality standards. The documentsproduced during the transcription process are critical components ofhealth care records. Therefore, the accuracy of the transcriptionprocess constitutes the most important aspect of the quality policy.To ensure that transcription is accurate and free of errors, regularmonitoring and control of the process is necessary. The attention inwhich the transcription department gives to quality should reflect arealization that even the minor errors in medical record had hugerisks on the health of the patients. Additionally, a small error inmedical transcription has a direct impact on the perceived competenceand credibility of the doctor giving the dictation. It is alsoimportant to note that there are numerous cases involving medicalrecords in the modern society, emphasizing the importance of qualitymanagement in medical records (Burns & Maloney, 2003).
Thereare several errors that are very common in medical transcription.While some errors are considered critical, others are not critical.Some of the critical errors which have serious consequences includemisuse or incorrect use of terminologies, omission of key words,wrong patient or author information. Non critical errors may includewrong spelling, grammar errors, typos, inflammatory remarks, failureto flag or wrong format. However, in implementing a quality policy inthe transcription department even minor errors should not be ignored.To determine the accuracy and thus the quality of a transcriptionmedical record, the document should be compared to the actualdictation. Reading the document does can not identify critical errorsin the documents. The review should also be based in the resourcesand quality standards available to the transcription department. Forexample, both internal and external standards should be put intoconsideration. Additionally, it is important to numerically quantifythe accuracy rating and compare the rating with the requirement ofthe quality manual. For example, quality manual may demand 100percent accuracy in reference to critical errors and 98 percentaccuracy for minor errors. In determining the quality and accuracy oftranscription, it is important to disclose all the benchmarks,standards and guidelines used (Burns & Maloney, 2003).
Burns,L. & Maloney, F. (2003). Medicaltranscription & terminology: an integrated approach,Albany, NY: Thomson/Delmar Learning.
Lindh,W. (2013). Delmar’sComprehensive Medical Assisting: Administrative and ClinicalCompetencies,Cengage Learning