WHERE Will We Move From HERE?
From curiosity, I made the decision to have a look back in the good reputation for medical transcription. Things I wondered was how did medical transcription get its start and just what was the outcome from the medical transcription profession within the medical industry. In researching a brief history, I came across a similarity in the current electronic health record systems using the pre-1960’s period of time and today question – where will we move from here?
Things I learned was that before the 1960’s physicians essentially acted his or her own scribe. Each physician produced their own individual notes regarding someone visit, test or surgery utilizing their own type of notation and abbreviation. This managed to get very challenging to the occasion where others may need the data but were not able to decipher a physician’s handwriting or understand the notations and abbreviations used. Using the development of practices and hospitals and the requirement for research and focus, it grew to become essential to focus on standardization and discover methods to profit the physician in recording the medical documentation. Within the next couple of decades the medical transcription profession was created and ongoing to change as technology developed.
Within the 1960’s, physicians began to make use of medical stenographers who’d write lower the doctors’ dictation in shorthand after which type up their notes on electric typewriters. With the introduction of the small and micro cassette recorder within the late 1960’s, physician and scribe no more needed to be in person which permitted the transcribing to happen inside a separate room and at another time. Shorthand wasn’t any longer necessary because the stenographers could now type in the documentation from the dictation around the cassettes.
The 1970’s ushered in early word processing machines, making the task of editing and correcting text faster and much more efficient. The development of the brand new technology helped to grow the medical transcription profession as well as in 1978 the American Association for Medical Transcription (AAMT), now referred to as Association for Healthcare Documentation Integrity (AHDI), was created to assist support and promote the medical transcription profession.
In the 1980’s up through today, we view technology transform in the word processing machines to non-public computers that originally used diskettes to digital online abilities with faster processors and software with auto-correcting plus spelling and grammar checking. Dictation technologies have also gone from micro-cassettes to digital recorders to voice recognition. With this particular evolving technology, the medical transcriptionist must learn and adapt right together with it. Not only typists, however, medical transcriptionists are medical language experts additionally to being medical documentation experts.
Based on the AHDI website, quality medical transcription requires above-average understanding of British grammar and punctuation excellent auditory skills, allowing the transcriptionist to interpret sounds almost concurrently with keyboarding advanced editing skills, making certain precision of transcribed material versatility being used of transcription equipment and computers and complex analytical skills, employing deductive reasoning to transform sounds into significant form. The medical transcriptionist is really a professional who takes the raw audio file and translates that into quality documentation.
The medical transcriptionist is a quality link for documentation between physician and medical records because the 1960’s. This relationship permitted the main focus to become put on patient care through the physician. Recent technology advances of electronic health records (Electronic health record) and also the Health It for Economic and Clinical Health Act (HITECH) which mandates physicians and hospitals to transition to Electronic health record, nevertheless, has lessened this unique link and introduced physicians into the scribe role.
The Electronic health record systems have numerous positive advantages however these advantages are offset by physicians being dissatisfied with getting to take more time doing data entry and clerical documentation which affects their interactions with patients because they divide time between your patient and documenting the individual record. Inside a reaction to the plummeting degree of satisfaction of Electronic health record systems by physicians, a brand new developing transcription trend is happening – the medical scribe. This trend moves the scribe role away, once more, in the physician.
So, may be the medical scribe where we move from here or exist other trends browsing the wings for all of us to uncover? Clearly, this sort of profession works well with the eye from the patient once the physician and scribe roles are separated. Physicians can perform what they’re best educated to do for and healing patients and scribes can perform what they’re best educated to do in delivering quality documentation. This mutually advantageous relationship between physician and scribe benefits not just one another but is really a positive for that medical industry.