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Ask the expert: Use medical transcriptionists to avoid unnecessary delays in record-completion

EHR Connection, March 26, 2007

Q: We have recently begun speech recognition and have been instructed to do as few edits as possible to enhance system learning and to gain the most productivity from the system.

For example, medical transcriptionists are not to add headers or subheaders, unless the provider dictates them. Staff feel that we need some standardization to provide a consistent report format.

Should we add some standard headers and subheaders to reports, even though providers do not dictate them? Is there a standard report format we should use?

A: Standard headers and subheaders, as well as other document-related standards, add value, both by ensuring that patient reports include required information and by facilitating access to, and use of, the documents for subsequent clinical and administrative purposes.

Although it's great if providers dictate such information, having
transcriptionists insert it when they don't can avoid unnecessary delays in the completion and, therefore, availability of the documents.

As for standard report formats, some years ago I co-chaired, along with two physicians from The Joint Commission, development of the Standard Specification for Healthcare Document Formats, published by ASTM International.

To review a summary of the document, you can go to www.astm.org and type "E2184" in the standard search box at the top. Then, click on "Active Standard E2184" at the top of the page it takes you to, and a summary will open.

If you would like to become involved in the development and review of an update to this standard and other transcription-related standards, you can contact Brenda Hurley, who chairs the ASTM E31.15 Subcommittee on Health Information Capture and Documentation, at bhurley@medwaremt.com.

Claudia Tessier, CAE, RHIA, vice president of the Medical Records Institute in Boston, answered the previous question.

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