Medical records contain confidential or personal information of patients. Apart from the physicians and nurses, transcriptionists also come to know the patient data; personal health information contained in the medical records. Anyone in the Healthcare Team is to have ethical values, keeping the confidentiality and protecting the privacy of the patients’ health information. Disclosing the personal information contained in the medical records would be breach of ethics and HIPAA Compliance. Professionalism calls for confidentiality and privacy for each patient.
Proficiency or Professionalism calls for accuracy, completeness, quality and quantity in one’s work. It cannot be achieved within a short period; however, it can be achieved through consistent and assiduous work. Of course, there will be a supervisor responsible for quality control. All the same, one is to develop an attitude of independence and responsibility for one’s own work. Nobody is perfect or impeccable. Blunders or mistakes might pop up. Keep in mind; mistakes have power to turn you into a better person than you were before. Mistakes are nothing but stepping stones to learning, but never key in any word unless you are sure it fits in.Its not possible for a transcriptionist to make cent percent transcription correctly . So here we have good quality editors for reviewing the work of this transcriptionist.
Success does not consist of never making mistakes but in never making the same one twice. –G. B. Shaw.
Why should there be any Health Record or Medical Record?
What does a Medical Record consist of?
How is it related to Medical Transcription?
These are some of the doubts that any layman might have. The Medical Record is a “proof of work done”. It is essential to gauge the quality of care provided to a patient. It consists of documentation to fulfill Federal State and Joint Commission on Accreditation of Health Organization standards and regulations and those for reimbursement and third-party payer requirements as well. Medical Record is essential for the medico legal protection for patient, physician, facility, and staff.
We are to admit the truth that none of us is “Mr. Know All”. In the ongoing Medical Transcription career, every one is likely to come across something or other for the first time in life. There and then, if we share it with others, it would be of immense help and value. The fact that we are ignorant of something doesn’t justify it doesn’t exist. To cite one example, “There is no change in his penmanship.” As long as you don’t know there is such a word which means a person’s handwriting, and if the dictation is fast and faint, you will hear anything but the word. At the most, some may key in “pen” followed by a blank! It may not occur many to consult a dictionary. If we have the spirit of sharing, such bloopers can be easily avoided in future, and it would enrich our vocabulary as well.
Almost every job entails drudgery as it is repetitive in its nature. There will be no change or variation whatsoever. You are compelled to do the very same thing in a routine manner. With regard to Medical Transcription, it is totally different. It has been already said that Medical Transcription is an exciting career, never boring. No two persons are similar, so are their problems. People and their problems are never boring and medical science is ever changing. Accordingly, it is sure that you will begin to experience the fascination and appreciation for medicine. The experience and knowledge you have hitherto acquired will ignite you further and further. Once you are into this career, you will tend to explore more and more and you will have no time to get bored.
Healthcare Industry is undergoing rapid technological advancements. However, a skilled Medical Transcriptionist need not be apprehensive about the future as there will be tons of work with the clinics and hospitals. With the emergence of speech recognition software and other related technologies, never think that the future of Medical Transcriptionists is on the verge of sinking. On the other hand, as the speech recognition software has many inherent limitations, it increases the scope for the Professional Medical Transcriptionists. No software can excel the cognitive and analytic potentials of man.
A well-read, well-informed, ahead-of-time professional is already part of this evolution and will continue to evolve because he is willing and even eager to make changes and keep abreast with the advancements in the industry. Make sure you get full leverage from the company you work to catch up with advancements.