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What's wrong with this picture?
A look at a troublesome practice in patient care documentation that places a legal burden on medical transcriptionists and should be of concern to everyone in the profession.
Contemporary issues in HIM. The application layer--III.
We have seen document preparation systems evolve from basic line editors through powerful, sophisticated desktop publishing programs. This component of the application layer is probably one of the most used, and most readily identifiable. Ask grade school children nowadays, and many will tell you that they have written a paper on a computer. Next month will be a "fun" tour through a number of other application programs we find useful. They will range from a simple notebook reminder to a sophisticated photograph processor. Application layer: Software targeted for the end user, focusing on a specific application area, and typically residing in the computer system as distinct components on top of the OS. Desktop publishing: A document preparation program that begins with the text features of a word processor, then adds the ability for a user to incorporate outputs from a variety of graphic programs, spreadsheets, and other applications. Line editor: A document preparation program that manipulates text in a file on the basis of numbered lines. Word processor: A document preparation program that can, among other things, reformat sections of documents, move and replace blocks of text, use multiple character fonts, automatically create a table of contents and index, create complex tables, and combine text and graphics.
PC system configurations for today's MT.
The proliferation of high-tech, low-cost PCs has made it easier to break into the world of personal computing. There are many very satisfactory systems available for today's consumer for around $1500 to $2000. My initial hardware recommendation for a system set-up for the individual medical transcriptionist or office environment is shown in Figure 1 below.
The transition from signature to authorship.
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The quality of patient care documentation.
Medical transcriptionists can attest to the accuracy of their transcription, but they cannot attest to the accuracy of patient or provider identification. The quality of patient care documentation can only be attested to by provider review and signature, i.e., through authentication.
AAMT (American Association for Medical Transcription) position paper. Providers' signatures.
Medical transcriptionists are medical language specialists who transcribe dictated patient reports. They interpret and edit raw data (dictation) in as complete, clear, consistent, and correct a manner as possible. Medical transcriptionists can attest to the accuracy of their transcription; they cannot attest to the accuracy of the dictation on which it is based. Patient care and well-being are at risk if proper attention is not given by the healthcare provider to the content of the patient record before the provider's signature is affixed. The provider's signature communicates accuracy of record content that only the provider can give; thus, delegation of authority to affix signatures is inappropriate and should not be allowed.
Signs of the times.
For the MT who experiences downsizing, it usually means hitting the keyboard faster and compromising quality.
A solution to an age-old problem: the missing report syndrome.
A look at how one medical transcription department solved the problem of missing discharge summaries without requiring physician redictation.
MTCP (Medical Transcriptionist Certification Program) to institute Code of Conduct Policy.
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Results of the first written core certification exam.
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Implementation of voice recognition technology at Provenant Health Partners.
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The new role of transcription systems in the computer-based patient record.
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Can medical transcription be taught in the classroom?
The results of the concentrated transcription program provided objective information that gives credibility to both sides of the transcriptionist training debate. In addition, the results provided the objective data needed to support changes in the curriculum. Students who are exposed to solid classroom teaching, coupled with enough opportunities to develop and practice transcription skills, have a better chance for success than those who rely solely on classroom instruction or solely on experience or on-the-job training. It is clear that increasing the number of hours of actual transcription results in an increase in the productivity and accuracy of the student's medical transcription.
An apples-to-apples comparison: standard units of work measure for medical transcription.
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Employment practices and the dignity of the MT (medical transcriptionist).
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AHIMA transcription guide--1994.
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Basics of salary negotiation.
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