By documenting the process of care is important for the operational aspects of health facilities, it is important to have some important tips to ensure that patient medical records meet the requirements. Ahdi Keep this in mind, AIDC and AHIMA has created guidelines that follow the model of the Plan Do-Check-Act
Act – the continuous improvement of quality
Because quality is a key word in the medical transcription process, the quality improvement process should be proactive rather than reactive. This quality improvement program should aim to prevent errors since there is to correct errors after the fact. For this purpose, the main program to significantly improve quality:
- Review
- Reviews
- Communication
- Monitor
Quality programs should focus on improving all aspects, including:
dictating machines: sound quality is greatly to the quality of the transcripts. It is important to address this problem by examining in detail all kinds of dictation devices to determine which is the best performance of the production ones. It is also important to consider that the working device to avoid audio problems because the word is cut, damaged word, etc.
Author of education: Since the origin of health professionals telling transcription through the encounter between patients, it is important to educate authors on the dictation of best practices. These may include:
- Choosing the right of dictating machines
- Know the equipment
- The importance of the choice of environmental voice dictation free
- The practice of determining the type of report at the beginning of the dictation, etc.
- Use the correct speed dictation
- It is also important to establish a forum for feedback in both directions between the medical support team / / clinic / hospital and Transcribers
Scribes: dictated copy of the transcript is located to liability for a medical transcriptionist. It is important to provide the means to produce quality transcripts transcribers. These may include:
- Training
- Provide Resources
- Provide Feedback
- Use the information as a learning opportunity
- Give out samples difficult writer
- Provides a format / template / macro / normal
- Assign a mentor for new transcribers
- Provide incentives for quality
Some accounts: This is to solve problems specific to certain accounts make it easy for transcriptionists to product quality. These may include:
- Easy to use accounts program details
- Updated continuously specify leaflet included
- List of individual health professionals to maintain the account, etc.
It can be seen as a process of continuous quality improvement to the quality of medical transcription for most.