WHERE DO WE GO FROM HERE?
Out of curiosity, I made a decision to have a look again on the historical past of medical transcription. What I questioned was how did medical transcription get its begin and what was the impression of the medical transcription career within the healthcare trade. In researching the historical past, I found a similarity in at present’s digital well being document techniques with the pre-1960’s time interval and now query – the place will we go from right here?
What I discovered was that previous to the 1960’s physicians principally acted as their very own scribe. Every doctor created their very own private notes concerning a affected person go to, check or surgical procedure utilizing their very own fashion of notation and abbreviation. This made it tough on the event the place others might have want of the knowledge however have been unable to decipher a doctor’s handwriting or make sense of the notations and abbreviations used. With the expansion of practices and hospitals and the necessity for analysis and examine, it grew to become essential to work on standardization and discover methods to help the doctor in capturing the medical documentation. Over the following few many years the medical transcription career was born and continued to remodel as new applied sciences developed.
Within the 1960’s, physicians began to make use of medical stenographers who would write down the medical doctors’ dictation in shorthand after which kind up their notes on electrical typewriters. With the event of the mini and micro cassette recorder within the late 1960’s, doctor and scribe not needed to be head to head which allowed the transcribing to happen in a separate room and at a later time. Shorthand was not obligatory because the stenographers may now kind up the documentation instantly from the dictation on the cassettes.
The 1970’s ushered within the early phrase processing machines, making the job of modifying and correcting textual content faster and extra environment friendly. The introduction of the brand new expertise helped to increase the medical transcription career and in 1978 the American Affiliation for Medical Transcription (AAMT), now generally known as the Affiliation for Healthcare Documentation Integrity (AHDI), was fashioned to assist assist and promote the medical transcription career.
From the 1980’s up by way of at present, we have now seen expertise remodel from the phrase processing machines to non-public computer systems that originally used floppy disks to digital on-line capabilities with sooner processors and software program with auto-correcting plus spelling and grammar checking. Dictation expertise has additionally gone from micro-cassettes to digital recorders to voice recognition. With this evolving expertise, the medical transcriptionist should be taught and adapt proper together with it. Extra than simply typists, nevertheless, medical transcriptionists are medical language consultants along with being medical documentation consultants.
In accordance with the AHDI web site, high quality medical transcription requires above-average data of English grammar and punctuation; glorious auditory expertise, permitting the transcriptionist to interpret sounds virtually concurrently with keyboarding; superior proofreading and modifying expertise, guaranteeing accuracy of transcribed materials; versatility in use of transcription gear and computer systems; and extremely developed analytical expertise, using deductive reasoning to transform sounds into significant type. The medical transcriptionist is an expert who takes the uncooked audio file and interprets that into high quality documentation.
The medical transcriptionist has been a top quality hyperlink for documentation between doctor and medical information because the 1960’s. This relationship allowed the first focus to be positioned on affected person care by the doctor. Current expertise advances of digital well being information (EHR) and the Well being Data Expertise for Financial and Scientific Well being Act (HITECH) which mandates physicians and hospitals to transition to EHR, nonetheless, has lessened this beneficial hyperlink and introduced physicians again into the scribe position.
The EHR techniques have many constructive benefits however these benefits are offset by physicians being dissatisfied with having to spend extra time doing information entry and clerical documentation which impacts their interactions with sufferers as they divide their time between the affected person and documenting the affected person document. In a response to the plummeting degree of satisfaction of EHR techniques by physicians, a brand new creating transcription development is happening – the medical scribe. This development strikes the scribe position away, as soon as once more, from the doctor.
So, is the medical scribe the place we go from right here or are there different traits ready within the wings for us to find? Clearly, the medical career works greatest for the curiosity of the affected person when the doctor and scribe roles are separated. Physicians can do what they’re greatest educated to do in treating and therapeutic sufferers and scribes can do what they’re greatest educated to do in delivering high quality documentation. This mutually helpful relationship between doctor and scribe advantages not solely one another however is a constructive for the healthcare trade.