Quality is critical in medical transcription. While the medical transcriptionist is required to make sure that he/she meets the quality goals the medical transcription industry has set, the reviewers have to keep an eye on the work making sure there are no errors in medical records. The Association for Healthcare Documentation Integrity (AHDI) says this about the quality goals in the field:
(Source) Transcription accuracy therefore should be monitored regularly to ensure quality documentation and to ensure that medical transcriptionist professionals receive timely and consistent feedback. Attention to quality should reflect an understanding that even minor errors in the record potentially can create health risks for a patient, and can diminish the credibility and perceived competence of the healthcare provider.
AHDI suggests that a medical transcriptionist should get constant feedback on his/her work so that there is no repetition of errors in future. Talking of errors, let’s look at how AHDI defines medical transcription errors.
- Critical Errors: These are the ones that can impact the safety of a patient. The industry has zero tolerance for these errors. A medical transcriptionist is required to achieve 100 percent accuracy with respect to critical errors.
Incorrect patient information, incorrect names and doses of medicines, incorrect values in test results, incorrect test names, and missing a part of the recorded information amount to critical errors. - Major Errors: These errors are the ones that impact the integrity of the medical document. One has to achieve 98 percent accuracy with respect to major errors.
Incorrect spelling of English words and medical terms, incorrect inferences owing to incorrect verbiage, failure to comply with protocols and policies, failure to highlight any missing information, and intentional highlighting of information cause major errors. - Minor Errors: Minor errors are not factual errors, marked by the areas of improvement in the medical document. The industry requires that you achieve 98 percent accuracy with respect to minor errors
Minor errors include errors in punctuation and grammar, inconsistency of format, and typing errors not amounting to any change in the meaning of content.
Along with meeting every deadline, the medical transcriptionist has to ensure that he/she meets every quality goal.
