Medical Records: Always in Demand
If it wasn’t written down, it didn’t happen. This is a serious but familiar refrain to all Healthcare Documentation Specialists/Medical Transcriptionists (HDSs/MTs), and to all medical professionals who deal with patients’ medical records. This emphasizes how important the documentation of all patient encounters is—files that are requested by the tens of thousands every day from the offices of lawyers, insurance companies, auditors, and patients themselves. These requests can be overwhelming to hospital information technology (HIT) departments, as each record can be requested numerous times, either manually in person, by USPS, or electronically. Since Covid-19 and the ensuring pandemic, patients have been encouraged to utilize the patient portal, which eliminates problems such as handwriting inconsistencies.
Why In Demand?
Why are these records in such demand? Court cases can require medical records, sometimes the death of a person requires the survivors have documentation, it could be insurance company requirements, or simply an individual keeping track of their yearly visit to their primary care physician. The reasons are as various as the requests; however, the records are available; it just may take a minute to get them processed and ready to be picked up. Yes, picked up. Having them sent out might involve even more time.
Processing of Requests for Medical Records
The processing of requests can take several forms. For example, one employee may devote an entire day to reviewing requests and sending the information to the printers. The next day, those same records would be reviewed, sorted, coordinated, and mailed—all of which is time consuming. If the resulting records are copied to CD for the requesting clients, as happens in radiology for x-ray, CT scan, and MRI results, that might triple the administration time.
Importance of Transcription
The United States is still dealing with areas of the country with no access to Wi-Fi or to broadband services; therefore, these providers still must handle their records by hand. This, ultimately, costs more than the efficiency of responding electronically. Broadband is part of the infrastructure that needs to be installed throughout the country plus, where it is installed, must be properly maintained.
So, with medical records always in need by diverse authorities and otherwise, it is important to keep them current and ready to transmit—either electronically or by hand. This means our physicians, PAs, and nurses must document every patient encounter; our HDSs/MTs must keep dictated reports transcribed; QA must keep transcribed documents reviewed and corrected, ready for HIT to convey them into offices all over the world!
Written by Patricia A. Ireland, CMT-R, AHDI-F
Blackstone Medical Transcription Instructor/Consultant
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Blackstone Career Institute provides an online medical transcriptionist course that will prepare you for entering the career force and ensuring that your skill sets are ready to meet the demands of this job. With your course, you will receive a foot pedal and will have opportunities to practice typing to improve your accuracy and speed with the keyboard. Master medical transcription practice using modern transcription equipment. Gain a working knowledge of medical terminology, medical diagnoses, and laboratory procedures. Receive online access to BenchMark KB, Quick Look Drug Book, and medical abbreviations. Through Blackstone’s comprehensive Medical Transcription Training, students can see the employment opportunities that are available for transcriptionists with formal education.
Certification as a Medical Transcriptionist
Graduates of Blackstone‘s Medical Transcription training program are qualified to sit for the Registered Healthcare Documentation Specialist (RHDS) exam, administered by the Association for Healthcare Documentation Integrity (AHDI) and after gaining work experience the Certified Healthcare Documentation Specialist (CHDS) exam offered by the Association for Healthcare Documentation Integrity (AHDI).