Practicing medicine requires rigorous precision. Where else can a single misplaced decimal point mean the difference between a healthy patient and a dead one? That’s why every process involved in the practice should adhere to elevated standards. However, doctors, nurses, and administrative staff are human, too, and documentation can be a heavy burden. Medical transcription companies (the good ones, at least) have come a long way to help with the ever-present battle with paperwork at hospitals, though it doesn’t end there. Proofreading checklists for medical transcripts are a must—for both the practice and the transcription service provider.
In this article, you’ll learn how:
- Proofreading checklists help medical transcriptionists maintain accuracy rates of 99% and above — a requirement in the healthcare sector.
- There are many to mention, but some of the most common transcription mistakes involve incorrect medical terminology, missing words, spelling errors, and improper punctuation.
- When choosing a medical transcription company, the main factors to consider are HIPAA compliance, US-based operations, EMR system compatibility, and clear turnaround times.
Why Is Proofreading Checklist Important for Medical Transcripts?
Medical transcription is a time-saving process, so, tacking on a proofreading checklist at the end can seem like a waste of time. However, given that the risks for inaccurate transcripts include patient mortality and career-ending legal action, the checklist should be a top priority. As a result, transcription companies and even hospitals, clinics, and other medical facilities need a checklist for medical transcription to spot potentially fatal errors from ever making it to the hospital floor.
Physicians are busy, and the back-end quality assurance process can barely match that pace. That’s one of the reasons why medical transcribers should implement thorough checklists. It also helps other trained and experienced transcriptionists verify every critical aspect of the documentation, like demographic details or clinical terminologies.
Potential Consequences of Medical Transcription Errors
As I mentioned earlier, medicine is a particular and precise practice, and any error, no matter how small, can snowball into a disaster. Here are some of the most significant consequences of inaccurate transcripts:
Consequence | Why It Happens |
Patient Misidentification | Patients with similar names or birthdays can get confused with each other, especially during high-volume transcription periods. |
Medication Dosage Errors | Incorrect decimal points or mix-ups in the measurement units can happen during rushed documentation. |
Treatment Delays | The transcriptionists might end up wasting time going back and forth due to medical terms that aren’t clear enough. |
Insurance Claim Rejections | The procedure codes entered by the transcriptionist don’t match what insurance companies need to see. |
Legal Liability Issues | An unclear transcript of patient consent could result in legal issues for the transcriptionists and the hospital. |
Care Coordination Failures | Wrong referral details prevent smooth provider-to-provider handoffs. |
Patient Anxiety | Patients will be worried when they see mistakes in the records, which will cause anxiety. |
Quality Metrics Impact | Documentation mistakes can significantly affect hospital compliance ratings. |
What Are The Common Medical Transcription Errors to Check?
There are tons of errors that medical transcribers should closely watch out for.
Incorrect Medical Terms
In the rush of documenting patient encounters, even the most experienced practitioners can sometimes mix up similar-sounding terms. An infamous medical term mix-up is between hypertension and hypotension—it’s a tiny prefix difference that can completely change the required treatment.
Although seemingly minor in written form, confusions like these can endanger patient outcomes as they affect treatment protocols. When these errors occur in official documentation, they can set off a chain reaction of misunderstandings that ripple through the entire healthcare organization, and that is where legal matters can join in the action.
Missing Words In Medical Notes and Reports
Medical documentation suffers the most when essential words are missing. Let’s consider, for example, a medication order that says “take tablets daily” instead of “take 2 tablets daily”. The first one is vague, while the second one is more precise. That missing number could affect patient care or lead to severe consequences.
These gaps often occur when multiple interruptions break the flow of thought, resulting in fragmented information. Instead of an easy reference, the documentation becomes a game of “Guess The Word.”
This is why reliable transcription companies like Ditto Transcripts implement quality control measures beyond proofreaders. Each document must pass through multiple rounds of review, where specialists perform stringent three-level quality checks.
Spelling Mistakes in The Transcripts
In reality, errors can creep into medical documentation even with the most careful typing.
While most healthcare providers will catch obvious errors, like infractions instead of infarctions, such a tiny mistake can still be overlooked during urgent situations.
That’s why transcribers need to check each line after typing to ensure that there are none of these small but potentially significant errors.
Typing Mistakes While Transcribing
Experienced medical transcribers understand that transcribing medical notes requires synchronized movements across keyboards, though sometimes, these movements go terribly wrong.
One classic example is a single misplaced finger turning something like normal saline into formal saline.
Prescribed turnaround time often creates pressure, which is sometimes the root cause of these typing errors. Worse, these errors can multiply quickly if not caught early in the quality assurance process. So, beware of these seemingly simple mistakes—because a few minutes of checking can save a patient’s life or a doctor’s career.
Words That Wander Off-Course
The challenge of preserving authentic medical language while ensuring clarity creates a balance between accuracy and clarity, as even the smallest editorial changes can alter meaning.
Let’s say a transcriptionist is attempting to “improve” the physician’s dictation. He changed the “blood sugar tends to run high” to “patient demonstrates elevated glucose levels.”
Although technically correct, this over-editing loses the physician’s intentional emphasis on the pattern of hyperglycemia. It’s only subtle shifts in jargon in our eyes. However, it can affect the physician’s integrity or, worse, impact the interpretation of clinical patterns.
Transcription services should maintain strict guidelines for preserving the original voice while maintaining clarity in medical transcripts. This means knowing when to preserve colloquial medical expressions that carry specific meaning within the medical community or when minimal editing truly serves the document’s purpose.
How to Choose a Medical Transcription Service
Transcription companies are a dime a dozen today, and many offer some form of medical transcription services. Knowing who utilizes a reliable proofreading checklist for medical transcripts or any measures to ensure accuracy can be challenging. However, there are several different qualities you should look for in any agency you hire.
Rahul Varshneya, Cofounder of medical software development company Arkenea, had great advice on the subject:
“When choosing a transcription service for your facility, you should consider one that is compatible with your current electronic medical records (EMR) system if your practice has one. Many services offer EMR integration and free technical support so that transferring and filing patient records is easy.”
Ditto Transcripts, for example, will accept all types of audio files and even come to work in your office. Not all agencies are so flexible; some may have systems incompatible with your EMR system and the files it produces.
What Else to Look For?
You’ll want to look for American-based companies that are HIPAA compliant. These agencies are working at the highest level of security possible. They will go out of their way to ensure that all privacy, security, and HIPAA regulations are followed carefully.
Look for agencies with legitimate US addresses and government registrations, such as SAM, and their business licenses are in good standing with whatever state they are registered within.
Keep in mind that while agencies outside of the country may offer slightly cheaper rates, they’re prone to higher rates of inaccuracies in transcription and much more likely to put you at a major security risk.
Several years ago, a transcription company in India caused a huge data breach when Google indexed medical files belonging to 32,000 US patients, and that is far from the only case.
The last thing to look for is a clear process that the agency has in place to deliver the work well and on time. Many will have processes that include file submissions, transcription, quality assurance, report delivery, and file storage.
The agency should be able to define clear turn-around times (TAT), which often vary from 2, 4, 8, 12, 24, or 48 hours after submission in medical transcription services. Check to see if the agency offers STAT delivery times, which can assure rush delivery when needed (though often at a rate increase).
Here’s a quick summary of what to look for:
- American-based companies with business licenses, addresses, and bank accounts
- Government registrations and certifications
- Transparent billing structures and payment options
- Clear turn-around times are available, and processes are in place to guarantee accuracy and quality
- Robust proofreading checklist for different types of medical transcripts
- Accepts whatever type of audio files your EMR produces
- HIPAA and HITECH-compliant
- Experienced with specialized medical transcription services
- High guarantees of accuracy
- Appropriate insurance policies, such as general liability and cyber liability
Medical Transcription Services Specialty Areas
If you’re considering medical transcription services and are worried you won’t find someone with experience in your specific field, you can rest easy! We offer all of the following specialty services for transcription and more:
- Adolescent and pediatric medicine
- Allergy immunology
- Anesthesiology reports
- Cardiology reports
- Cardiology transcription
- Chart notes
- Clinical notes
- Clinical summary (ies)
- Cytopathology reports
- Dental report and transcription
- Dermatology reports and transcription
- Discharge summaries
- Doctor Note Transcription
- Electrophysiology Reports
- Emergency Room
- Endocrinology
- ENT Reports
- Family Practice transcription services
- Gerontology transcription and reports
- Group practice work
- OB/GYN – Gynecological transcription
- H & Ps
- Hematology reports
- Hepatology transcription service
- Infectious disease reports
- Internal medicine
- Neurology transcription
- Ophthalmology transcription
- Oncology reports
- Orthopedic transcription
- Pathology transcription
- Patient notes
- Pediatric transcription
- Podiatry transcription
- Progress notes
- Psychiatry transcription
- Psychology transcription
- Pulmonary transcription
- Radiology transcription
- Surgery notes transcription – pre-op and post-op
If you’re looking for something a little different and don’t see it on our list, you can contact us here to learn more about what we can do for you.
Ditto Understands That Proofreading The Transcripts is Crucial
Medical transcription services are highly specialized. At Ditto, we’re well-trained and experienced. We can help you speed up your process, help more patients, and have stronger, more accurate records than ever before, all at a lower cost than any other option.
And yes, we implement a robust proofreading checklist for medical transcripts to ensure over 99% accuracy.
Interested in seeing how our medical transcription services can help? There’s no risk in setting up a no-obligation call, so get in touch and learn more about what we can do for you.
Ditto Transcripts is a HIPAA-compliant Denver, Colorado-based medical transcription services company that provides fast, accurate, and affordable transcripts for individuals and companies of all sizes. Call (720) 287-3710 today for a free quote, and ask about our free five-day trial.