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Medical Transcription, Real work At Home Business And Some Healthy Information
The importance of documenting the patient encounter is manifold as it helps in many aspects that contribute to the smooth running of healthcare facilities, besides being a statutory necessity. As healthcare services are critical it is important that the process of documenting the patient- healthcare professional encounter be subject to certain norms. The patient – healthcare professional encounter can be documented by various means, one of the most preferred being medical transcription; a process which converts dictation to text.
As medical transcription has an important supporting role to play in the process of healthcare, a best practices guide titled “Healthcare Documentation Quality Assessment and Management Best Practices” has been jointly created by AHDI, MTIA and AHIMA. One of the highlights of this manual is alignment with the Plan-Do-Check-Act cycle.
Each stage of the process is vital to ensure that the process of healthcare is documented keeping in mind that maintaining the highest standards of quality is a continuous process. The goal of this quality assessment program is to ensure that healthcare documentation is clear, consistent, accurate, complete and timely.
Plan: Planning policy guidelines for quality
This part of best practices for maintaining quality involves a set of standards for documentation that ensures accuracy, accessibility and overall value of the patient medical record as a resource for understanding the care process including diagnosis, treatment and progress.
To ensure this, the planning process should have principles that ensure:
· Verifiability: Any quality program should have standards and measures that are easily verifiable and these measures should be available to personnel at every level of the organization and to the end user of the transcript to ensure cross verification
· Definability: The error categories should be clearly defined
· Measurability: Measurable values for clearly defined error categories should be assigned and measurement methodology for errors should be clear to all the parties involved
· Consistency: The quality program should define error categories, values to be assigned to each category and there should be a standard method error determination.
· Integrity: The integrity of document can only be assured when there is a synchronized partnership between the originator of dictation and the medical transcriptionist. The healthcare professional dictating the notes should present information in a clear and concise manner and the medical transcriptionist should transcribe the document preserving the essence of the information provided by the healthcare professional
To this end the quality assurance program should be based on Quality Guidelines that ensure the following:
· Accurate and complete documentation ensuring that the essence of the encounter is captured
· A process of distribution of reports on a timely basis and a system for easy accessibility of past records to the relevant personnel
· A practice of periodical quality audits to study the process and assess where errors occur as a part of the ongoing quality process
· This process to be applied to medical transcription at all levels
· The assessment program should be consistent and unbiased
· The assessment program should be according to the principles of assessment agreed upon
· The results from the assessment process to be used as a learning tool to ensure recurrence of errors
· Access to the Quality Guidelines, assessment process to be made available to all the people involved in the transcription process.
To be successful a quality assurance program should be:
Proactive: Medical transcription being such a critical activity that contributes to the healthcare process, it is important for quality assurance program for medical transcription to be proactive. Being proactive ensures that solutions are available for problems before they turn into major issues
Realistic, scalable and financially feasible: Quality is a continuous process; therefore it is important that the quality assurance program should be realistic and cost effective
Simple and easy to implement: Creating patient medical records is a process that consistently needs to meet the quality constraints of accuracy and timeliness, keeping this in mind any quality assurance process has to be simple to be workable.
Secure and Confidential: Considering that the process of creating patient medical records involves working with confidential patient information and comes under the purview of HIPAA it is important that any feedback regarding quality keeps in mind the confidentiality norms
Inclusive of all aspects: Quality in the transcription process involves all aspects starting from the origin of the data down to the transcriptionist, proofreader and quality team, the quality assurance program needs to plan measures to include all these aspects
Reportable for trending and tracking purposes: The process of quality assurance is not only to ensure consistent quality documentation but is also a valuable input for education purposes
Timely: The quality assurance process should be scheduled in timely manner to ensure maximum results
Understanding the basics of Federal Regulations can be overwhelming to the Medical Transcriptionist (MT). With a career as a healthcare professional you will here this word a lot HIPAA
(Health Insurance Portability and Accountability Act).
This is a bill that was enacted in congress in 1996, with the main objectives, portability and accountability.
PORTABILITY:
Ensure the continuation of health insurance for workers and their families in times of job changes or loss.
ACCOUNTABILITY:
Protecting health data integrity while increase the effectiveness of the health care system, confidentiality and availability and preventing fraud and abuse.
The experts call this the most sweeping healthcare legislation in the last 33 years.
The most important part for HIM (Health Information Management), the department in which MT is one of its specializations, profession is in the title section: TITLE II, SUBTITLE F.
Administrative Simplification is the name of this part.
Four Rules of Administrative Simplification:
Information specifically about HIPAA including complete text of the regulation and more important links can be found Here.
HIPAA and your job as a MT can be quite over whelming, but don't let this stop you. HIPAA is designed to help you save money and time to make everyone's life easier.
HIPAA FOR MTs:
Sample Business Associate Agreement (sample agreement only, seek legal counsel).
Safeguarding Protected Health Information (PHI): Focus Points for Offsite Transcriptionists
MT Service Providers Transcription Agreement Check List
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Shrimp is full of cholesterol. But the real cholesterol danger lurks in the slyly packaged "cholesterol
free" cookie. You see, shrimp contains very little of the saturated fat that makes that cookie taste so good. And it's the saturated fat in food ─ not the cholesterol ─ that has the greatest effect on your cholesterol level.
No wonder people are confused.
Here's your guide to understanding what it all means, because what is clear is the link between high cholesterol in your blood and heart disease. You'll find out whether you need a cholesterol test and what "good" cholesterol is, along with quick tips for creating a heart ─ healthy diet. What you won't find is a recipe for those cookies.
Cholesterol, a white, waxy fat found naturally in your body, is used to build cell walls and make certain. Too much of it, through, can clog your arteries and eventually choke off the supply of blood to the heart, which is the reason high cholesterol is a leading risk factor for heart disease. Other factors that pur you at risk include:
WHO SHOULD BE TESTED: Everyone age 20 and older should have their cholesterol measured at least once every 5 years. It is best to have a blood test called a "lipoprotein profile" to find out your cholesterol numbers, according to the National Cholesterol Education Program.
BY WHOM: preferably your doctor, who can measure LDL as well as total cholesterol. If you use an outside service:
For more information on your cholesterol testing visit this web page for this free report.
This information was shared by me with you from: HEALTH magazine. Address: Health, P.O. Box 36863, Boulder, Colorado 80322.
Every time nurses or physicians treat their patients, they create records of what they have seen and done. Such as the results of x-rays and examinations or diagnoses and treatment plans. Medical Record Technicians are basically archivist who performs the important task of organizing and maintaining the medical documents.
Doctors and Nurses depend on the work of the Medical Records Technicians, who work hard behind the scenes, actively ensuring that all medical records and forms are all properly identified, signed and kept on file.
Anyone interested in this career should be prepared to work at a computer, for long periods. Since computer programs are used to manage and analyze the ever increasing amount of medical information.
The accuracy of all this information is very important. Medical Records Technicians must pay strict attention to details. This career offers satisfaction only in the challenges that arise on a daily basis, but also in the knowledge that Medical Records Technicians are helping provide high quality patient care.
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