According to the World Health Organization, one in every ten patients suffers from the consequences of unsafe medical care – 50% of which are preventable. Our healthcare professionals are in an uphill battle to provide the best possible medical care while avoiding burnout from 12-hour shifts, unending emergencies, and a lack of work-life balance. While no one questions the importance of accurate documentation in healthcare, there is a distinct gap between the exhausting situation in medical settings and that ultimate goal. That’s why medical professionals are encouraged to seek help from reliable medical transcription companies.
In this article, you’ll learn how:
- Healthcare professionals face overwhelming workloads, leading to lapses in documentation quality.
- Medical transcription services, especially those using human transcribers, can boost productivity, streamline workflows, improve physician work-life balance, and reduce healthcare documentation errors.
- Ditto’s 100% US-based human transcription delivers affordable services, high accuracy rates, fast turnaround times, HIPAA and HITECH compliance, and the best customer service in the industry.
What Is Clinical Documentation?
Clinical documentation is the detailed recording of a patient’s medical history, diagnoses, treatments, test results, treatment plan, medication usage, and overall progress throughout their healthcare journey. These documents are medical references for healthcare providers and legal records if required.
Clinical documentation takes many forms, including histories, progress notes, discharge summaries, and consultation reports – anything done by a doctor or medical professional in the interest of patient care.
The Importance of Documentation in Healthcare
Accurate healthcare documentation is the foundation of a working medical industry. Without it, medical professionals will be left scrambling for details, leading to issues with proper care, medical prescriptions, diagnoses, and more. Comprehensive documentation ensures that everyone involved in a patient’s care is well-informed, medically aligned, and able to make sound medical decisions based on clear records.
Now, each hospital, clinic, and care center has different documentation practices, though regulations aim to standardize the documentation process and the security safeguarding the workflow.
Healthcare professionals prioritize accuracy and quality in healthcare documentation – a difficult feat, considering they often work more than 8 hours every day.
So, they’ll need all the help they can get.
Does Inadequate Documentation Impact Patient Outcomes?
Accurate and adequate documentation is important in the medical field. Failing to ensure these can lead to ugly consequences, including:
| Inadequate Documentation Issue | Impact on Patient Outcomes |
| Incomplete or outdated medical records | Leads to adverse drug reactions, missed allergies, or inappropriate treatments. |
| Poor communication between healthcare providers | Causes treatment delays, misunderstandings, and clinical errors. |
| Missing documentation of clinical decisions | Results in legal risks and unclear treatment rationales. |
| Inaccurate or missing vital signs/lab results | Contributes to misdiagnoses and incorrect interventions. |
| Gaps in documentation across departments or shifts | Leads to fragmented care, repeated tests, and patient dissatisfaction. |
How Transcription Can Improve Clinical Documentation while Reducing Medical Errors
Accurate transcription can be a lifesaver for healthcare professionals drowning in paperwork. Here’s how it can help:
Captures Complete Clinical Records
We’ve all listened and written at the same time during school. But have you tried listening, writing, and forming a sound medical opinion, all at the same time, while your patient expresses the expected emotions that come with a serious medical condition?
Manual recording is still required since doctors cannot record patient consultations. However, once that’s all done, the physician can record the complete medical notes as an audio file, without having to write everything down.
These recordings can then be sent to transcription providers, who can convert them into accurate documentation for patient files and EHRs/EMRs.
Supports Clinical Documentation Improvement
Clinical Documentation Improvement (CDI) streamlines the collection and recording of healthcare records. Transcription is an excellent addition for healthcare facilities aiming for CDI since it captures everything and produces more accurate and detailed documentation than, say, a hastily scribbled note.
Improve Medical Coding
It’s estimated that medical coding errors cost patients, hospitals, and the government more than $20 billion annually. Errors in medical coding can stem from many things, though inaccurate documentation is one of the top reasons.
Transcription can help by providing medical coders with all the information they need to assign the most precise diagnostic and procedural codes, which improves billing accuracy, compliance, and reporting.
Mitigates Medical Errors
By adopting accurate transcription, medical professionals help avoid misinterpretation or improper oversight of patient care. Clean, accurate records alleviate missed medical histories, incorrect dosages, and more. Of course, this is predicated upon the transcription provider offering accurate services all throughout the process.
Why Should Healthcare Facilities And Clinical Services Avoid AI Transcription?
One of the most effective tips for improving healthcare documentation is to let the skilled humans do it. I know we’re all busy, and the world is trying to find new ways to automate every task possible. Some tasks, however, work better when completed manually, and medical transcription is one of them.
Many electronic health record systems today have built-in speech recognition and dictation storage options; some even feature native transcription features. However, automated transcription services are the last thing medical professionals should ever consider using.
While they’ll get the gist of the basic dictation, AI can misunderstand phrases and transcribe them as something completely different. This results in inaccurate patient records, clinical summaries, and surgical reports. Not only does this affect the patient’s health outcomes, but it also impacts the healthcare facility, staff, and investors.
The only way to ensure accurate documentation and transcription would be to manually review the original text file while listening to the dictation and making the edits, which would waste even more time. That’s not exactly the best circumstance to find yourself in after using AI for medical record documentation.
Dtick with human transcription service providers like Ditto, otherwise, you’re paying for the privilege of doing your own transcription twice.
Improve Medical Documentation and Patient Health With Ditto Transcripts
Healthcare documentation is vital, so selecting the right medical transcription agency is essential to effective patient care. However, finding someone to meet your medical transcription needs can take time and effort.
Luckily, you’re already looking at one of the best medical transcription providers in the market. Here’s why Ditto Transcripts is always a step ahead of the competition:
Expertise
Our medical transcribers are skilled in handling electronic health records (EHR) and electronic medical records (EMR), which streamlines your transcription process.
We can create custom programs to push our work into your EHR/EMR, so that patient records can be updated with the press of a button. You work on patient safety; we’ll work on making your lives easier.
100% Human Transcription
AI, machine learning, and automated speech recognition might always have the “easy-to-use” tagline, but they’re inaccurate regarding transcription.
These platforms and programs always stumble on medical terminology, making them liabilities rather than assets. They’re also prone to inconsistency and susceptibility to errors caused by audio issues and multiple speakers.
On the other hand, we offer 100% U.S.-based human transcription services for all medical transcription projects.
99% Accurate, All The Time
Medical jargon is not an issue with experienced medical transcribers. We combine excellent listening skills and years in the business to generate the most accurate transcripts.
Our transcription service guarantees more than 99% accuracy for every project. In fact, we offer editing and correction services for speech-to-text results from transcription software, giving the final transcript the care it deserves.
Rapid Turnaround Time
Our services ensure rapid turnaround time and access to medical records and reports 24/7. Electronic file deliveries are done within 24 hours or less.
Proven Track Record
Consistency and transparency are our core foundations. We’ve been in the game for over a decade and will be happy to provide client references upon request.
Industry-Defining Customer Support
Do you have a question about our service? Do you need your latest transcripts customized? Give us a call or send us an email, and our customer service representatives will get right on it.
HIPAA and HITECH Compliance
We are a HIPAA- and HITECH-compliant medical transcription service provider – something not every provider can claim. Our data security protocols ensure full protection of all your information to ensure confidentiality.
Ditto Understands The Importance of Documentation in Healthcare
Maintain high-quality patient care while we handle your health record documentation. Ditto’s medical transcription offers the best service in the industry – or your money back.
Call us or sign up for our free, commitment-free trial and experience the difference.
Ditto Transcripts is a HIPAA, HITECH, and CJIS-compliant medical transcription company based in Denver, Colorado, that provides fast, accurate, and affordable transcription services to companies and agencies of all sizes. Call (720) 287-3710 today for a free quote and ask about our free five-day trial.