Tips to Ensure Your Patient Records Remain Private
Are you looking for a transcription career? Look no further than being involved with patient records. You work for hospitals, clinics, doctor’s offices, and home health care companies. Sometimes you may work as an independent contractor.
Transcription’s Intersection with Medicine
Medical transcription is a diverse field. You get involved with making the patient record itself. Besides transcribing, you edit medical reports for typos. Physicians, nurse practitioners, or nurses and medical assistants take dictation even if they feel swamped in work. Medical transcribing is a growing field. Doctors grow tired of transcribing their notes that span types of notes, such as clinical summaries to surgery notes.
Transcriptionists trained in transcribing for medicine transcribe audio files, converting them into a pinpoint accurate transcript that follows the doctor’s formatting rules. Healthcare providers have to practice privacy concerns related to HIPPA. You are given handheld digital recording devices to record your notes, allowing them to speed up the process in the short term, taking too much time when recording dictations. Healthcare providers have to be careful how you put your notes together and who has access to these private patient records.
Keeping Doctor’s Field Notes Private
Digital handheld recorders or smartphone apps such as Voice Memos are installed by default on Apple devices are used to keep track of the data the doctor had accumulated while seeing a patient. Health care workers have to dictate any office visit, emergency room visits, diagnostic imagery (radiology) studies, op notes, chart reviews, and discharge summaries. There are plenty of situations to record. A medical transcriber has to write this up into written text that is easy to save while also shared with other physicians. Dictations are necessary to put together a certain way to have a record of a patient’s medical history, insurance claims, and diagnosis while also describing a treatment plan.
Medical Transcribing is not Just About Typing Verbatim.
Transcriptionists have to edit and format reports exactly how you need them to. Medical transcribing is a task that has to be completed manually the second a patient consult is over with. Electronic health care records have become trendy in modern times, but great care must be taken not to be hacked into if they remain on the computer. The transcriber has to understand what the doctor says, seeing as you also need to edit the piece.
High Stakes
You, the medical transcriber, are providing a valuable service. The transcriptionist has to be aware of medical technology at all times, only because they need to be. This is why transcription companies take the training of their employees very seriously. You need to type with accuracy because transcribers have to wade through possible errors in the transcription itself. HIPAA violations involve telling someone a patient’s personal medical history. Agencies must follow safety protocols to the letter. HIPAA is short for the Health Insurance Portability and Accountability Act; you have to choose the right agency that trains its transcriptionists in medical terminology.
Medical transcribers have to understand the sensitive nature of the documents they are working on. A transcriber needs a GED or high school diploma and completion of a certified medical transcription training program six months to years of training. You can also enroll in an associate’s level program. Certification is optional but is recommended only because the Association gives a national exam for Healthcare Documentation Integrity (AHDI). After the test, you earn the title of Certified Medical Transcriptionist (CMT). Degrees are essential proof that you are qualified and adequately trained to handle specific tasks and demonstrate that you got the necessary information and resources to move within a particular field as important as transcription.
