When ever challenges in medical transcription are mentioned, stringent deadlines and high quality goals top the list. The reason deadlines or quality goals become difficult is because of the interdependency of these two things. Meeting deadlines with poor quality or delivering high quality after the deadline renders your work useless. In today’s post, we will discuss the expected quality standards in medical transcription.

The Association for Healthcare Documentation Integrity (AHDI) has divided the errors in medical transcription work in three categories to standardize quality in the profession. The three categories of errors are: critical errors, major errors, and minor errors.

As the terms suggest, the critical error is the most important or critical one, the major error is less critical but still important, and the minor error is an error but not too important.

The medical transcription profession has zero tolerance when it comes to critical errors. Why? Because critical errors are the ones that can impact the safety of a patient. The medical transcriptionist, therefore, is required to achieve 100 percent accuracy with respect to critical errors. Now, what is a critical error? A critical error occurs if you put incorrect patient information, incorrect names and doses of medicines, incorrect values in test results, or incorrect test names in a medical record. Missing a part of the recorded information also amounts to a critical error.

The quality goal with respect to major errors is 98 percent accuracy. This means that you are not allowed to have more than 2 percent major errors in your medical records. Major errors are the ones that impact the integrity of the medical document. Incorrect spelling of English words and medical terms, incorrect inferences owing to incorrect verbiage, failure to comply with protocols and policies, failure to flag any missing information, and intentional flagging of wrong information cause major errors.

Minor errors are not factual errors. They are marked by the areas of improvement in the medical document. The medical transcription profession requires that you achieve 98 percent accuracy with respect to minor errors. Errors in punctuation and grammar, inconsistency of format, and typing errors not amounting to any change in the meaning of content contribute to minor errors.

AHDI suggests that a medical transcriptionist get constant feedback on his/her work so that there is no repetition of errors in his/her future work. Sound advice. What do you think?

It is not the deadlines that make medical transcription difficult but the quality expectations. The quality goals in the field are very high and they ought to be so. The information contained in medical records affects the health of people directly. A careless error on your part can put someone’s life at risk. It the critical nature of the information that makes the medical transcription work difficult.

The overall quality goal in the profession is 98 percent. Does that mean that there is scope for two percent error? Wouldn’t that put people’s lives at risk? The two percent that is not taken into account is the aesthetic errors. To get an idea of how it works, let me take you through the categorization of errors as defined by the Association of Healthcare Documentation Integrity (AHDi).

Critical errors: These errors are the ones that can impact the safety of a patient. Thus, as is expected, there is absolutely no tolerance for these 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. A medical transcriptionist is required to achieve 100 percent accuracy with respect to these.

Major Errors: These errors are the ones that impact the integrity of the medical document. 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. You have to achieve 98 percent accuracy with respect to these errors.

Minor Errors: These aren’t factual errors but are marked by the areas of improvement in the medical document. They include errors in punctuation and grammar, inconsistency of format, and typing errors not amounting to any change in the meaning of content. You have to achieve 98 percent accuracy with respect to minor errors.

Get the idea? Keep watching this space for more insights into the world of medical transcription.

The medical transcription profession expects the following of a transcriptionist:

• To deliver complete medical records in time
• To meet quality goals
• To ensure the security and confidentiality of medical data

Now, the quality goals in medical transcription are very high. While the overall quality goal is 98 percent, the goal with respect to critical errors is 100 percent. Let us look at what a medical transcriptionist has to deal with in terms of quality.

Critical Errors: The profession has zero tolerance when it comes to these errors. This means, the transcriptionist cannot afford to make even a single critical error. And this is obvious because critical errors can impact the safety of a patient. Examples of critical errors include 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: The medical transcriptionist has to ensure 98 percent accuracy with respect to these errors. These errors do not impact the safety of the patient but impact the integrity of the medical document. Examples of major errors include misspelling regular 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.

Minor Errors: Here again, the medical transcriptionist has to ensure 98 percent accuracy. These errors do not impact patient safety or document integrity. Minor errors are not factual errors; they are somewhat aesthetic in nature, marked by the areas of improvement in the medical document. Examples of minor errors include errors in punctuation and grammar, inconsistency of format, and typing errors not amounting to any change in the meaning of content.