The deadlines in the medical transcription profession wouldn’t have been deadly had it not been for the quality goals in the profession. The quality expectations in medical transcription are high because they ought to be so. After all, people’s lives depend on their medical record. A lapse on your part can impact a person’s life gravely.

The expected accuracy rate in medical transcription is above 98%. The Association for Healthcare Documentation Integrity (AHDI) has classified medical transcription errors into three categories. It has set quality goals for each type of error. Let’s look at these error types and understand the quality goals associated with them.

The first type of error is referred to as critical error. Critical errors can impact the safety of a patient. Obviously, you are not allowed to commit even a single critical error. 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.

The second type of error is the major error. Major errors do not impact the safety of the patient but impact the integrity of the medical document. These 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. The quality goal with respect to these errors is 98 percent.

The third type is the minor error. Minor errors do not impact patient safety or document integrity. Minor errors are not factual errors. They are marked by the areas of improvement in the medical document. Minor errors include errors in punctuation and grammar and inconsistency of format, and typing errors do not amount to any change in the meaning of content. With respect to these errors, the quality goal is 98 percent.

The quality goals in medical transcription are difficult. You already know that. And they ought to be difficult. After all, it is medical transcription that creates medical records of patients. A careless mistake can even cause someone his/her life. So, as a medical transcriptionist, you have got to deliver very quality work.

How does the profession quantify this quality? Well, the overall quality goal is at least 98 percent. And when it comes to critical errors, it is 100 percent. Talking of errors, let’s look at the categories of medical transcription errors as defined by the Association of Healthcare Documentation Integrity (AHDI). There are three types of errors: critical errors, major errors, and minor errors.

Critical errors are the ones that can impact the safety of a patient. This is the reason the profession has zero tolerance with respect to these errors. 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 are the ones that do not impact the safety of the patient but impact the integrity of the medical document. The medical transcriptionist has to ensure 98 percent accuracy with respect to these errors. 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 mark the areas of improvement in the medical document. They are a bit aesthetic in nature. Here again, the medical transcriptionist has to ensure 98 percent accuracy. 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.

Let me know if you have more questions about these errors.

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.

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.