Taking a Look at Medical Transcription

purpose of this paper is to review the electronic medical record and analyze its impact on

In this case, CAC technology also provides a connection between EHR documentation and transcription systems. Primarily, CAC technology in a healthcare environment has rapidly and drastically changed the process in which medical coding in health-information management. This is handled for a better productivity and efficient workflow solution, including production monitoring, coding review, management reporting, computerization of coding and auditing. Clinical documentation is ensuring that it has routinely generated medical codes from computer assisted codes (CAC). In addition, CAC technology has enabled healthcare organizations to recognize the revenue-cycle process as they increase their requirements towards improved quality. The complete implementation of the CAC technology is essential when improving the main necessities towards patients, such as the efficiency, quality, productivity, and management of their care. Last but not least, CAC technology has produced one of the best strategies for the challenges that the HIM professionals face as coding becomes one of the most important aspects of transitioning to

Along with the new technologies applying in healthcare, the documentation processes and storages also change from paper charts to computer-based electronic health records (EHR). Many healthcare organizations currently maintain patients’ health records in both formats of paper and electronic. The combination is known as hybrid health record system, which is used to assist in different methods that patients’ information is collected. Hybrid health records (HHR) contain specific patients’ health information. HHRs are stored manually and electronically in multiple places. Current patients’ health records usually contain both digital documents and handwritten notes. Patients’ data are electronically stored, such as laboratory, radiology tests,

Providing quality transcription services to customers are key. In the healthcare industry, proper documentation is vital as the records are considered legal documents. These documents

Accuracy of recordings and ease of understanding of patient information in medical records play central role in quality of

Typically non-value added activities account for 95% of the lead time and only 5% of the activities are actually adding value to the process. This can be easily seen on the above listed process flows for patients, technologists and the transcription report.

The field of healthcare administration is growing at a steady pace to bring about efficient service to all the patients (Harris, 2015). Currently, many specialists have emerged to ensure good health to all individuals at affordable rates. For instance, there is the healthcare documentation specialist, formally known as medical transcriptionists, who are highly-skilled health personnel, dealing with the process of transcribing, verifying, or converting spoken (voice-recorded reports) as dictated by a healthcare professional (Skurka, 2017). The prepared report henceforth becomes part of the permanent health record or history of the patient that can be used in future reference.

Medical record technician salary depends on several factors: the size of the city, the location, type employing institution, training and their experience. Entry level tech with a associate degree earn $20,000 - $30,000 a year. A tech with a bachelor degree earn $30,000 - $50,000 a year. if a medical record technician has five years or more experience earn $75,000 a year, (Encyclopedia, 2017).

Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary.

Health information technician works in a mixture job that includes equally office records administration and information technology (hit) duties. They normally work in a medical office, private clinic, or hospital environment. The key duty of this position is to keep patient records and make sure that new information is entered into systems as necessary by the caregiver and in agreement with administrative procedures; coding all procedures and facts of patient checkups must keep an eye on the standards necessary by insurance companies and Medicare. Also, the health information technician is projected to safeguard that computer systems needed for well-organized record keeping are sustained and advanced as necessary. They help complete any essential software upgrades to

A lot of things have evolved when it comes to patient records in the medical field. In medical facilities the patient records use to be in paper form. There would be multiple pages of patient information, doctor

All employees have the RHIT certification; one coder also has CCS for coding. The HIM technicians assemble and analyze records they handle release of information, handle the deficiency room, and they assist any doctors with dictations or transcriptions. The coders are strictly for coding but, if it is needed, they may help with dictation also.

Healthcare is a complex entity that encompasses a variety of specialties necessary toward meeting the needs of patient seeking clinical services. There are multiple communications necessary to efficiently meet patient needs. For many years detailed documentation, progress notes, specialty consults, and physician orders have been hand written. The legibility of this documentation was often illegible, and difficult to decipher, which resulted in clarification orders and often delays. The electronic medical record was introduced approximately 50 years ago with an ultimate goal of compiling healthcare information for immediate and future reference (Keller, 2016). Since the electronic medical records was initially implemented multiple versions have since been created. Successfully implementing the electronic medical record, requires a great deal of research to ensure that the specifications align with the organization’s short and long term goals.

Electronic Medical Records or Computerized Medical Record System what is it and what are the advantages along with the disadvantages of using this system? That is what we will discuss in this paper.

This paper is on my journey to be Medical Records and Health Information Technician. On every career path there are trials and tribulations that you will have to overcome. With Medical Records and Health Information Technician, you will have to learn skills, abilities, and have to be detailed oriented. Step by step this paper will guide you into becoming a good health information technician by filling you in on my journey. Nothing is an easy journey, but with the proper training and education from the right institution, you will be well on your way in your chosen career path.