The healthcare record belongs to the hospital, medical facility or office where it originated. It cannot be removed from the premises without a subpoena or court order. Although much of the healthcare record is maintained through computer software systems, most medical care facilities still maintain a “paper” healthcare record of some sort.
The healthcare record is maintained by the Health Information Department of hospitals and medical facilities and usually headed by a registered record administrator or an accredited record technician.
A former term for the healthcare record for over fifty years was “Medical Record.” The new term of healthcare record denotes both illness and wellness. The Medical Record Department name has also changed to Health Information Department.
What is the purpose of a healthcare record?
It is a measurement and documentation of care rendered in a medical facility. The healthcare record is used to plan, communicate and evaluate the quality of care given to each patient. It provides “proof” of work done for each patient. Documents are required to meet federal, state, and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) standards and regulations. In addition the documents contained in a healthcare record must meet regulations for reimbursement and third-party payer requirements.
The healthcare record is kept for legal protection for:
•The medical care facility
•The patient
•The staff
•The physician
The healthcare record can be used for:
•Research
•Compiling statistics
•Evaluation of healthcare delivery
The healthcare record originates:
•In the admissions department of hospitals
•Outpatient registration
•Emergency department
•Private physician facilities reception area
The major role of all departments of healthcare record origins is to:
•Collect patient identification and demographic information
•Correct spelling of patient's legal name and birth date is critical
The information collected is used to assign healthcare record numbers and is maintained for the lifetime of the patient. It is vital that the medical transcriptionist transcribe the identification and demographic information concerning a patient with complete accuracy as well as all other physician dictated reports. A transcribed incorrect date of birth or patient number can produce chaos in the Health Information Department and throughout the medical facility.
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On the other hand, it can be demanding, with deadlines that need to be met, and a very high standard of accuracy. Add that to changes in technology, and it's important you consider many factors before you spend money on your medical transcription education.
The first things to look at are your own skills. Can you type fast? Your transcription speed is generally slower than your typing speed. The faster you already are, the better.
How's your grammar? Spelling? If you have a lot of trouble in these areas, you're going to have a harder time succeeding as a transcriptionist.
What about your work space? While you don't have to worry about others overhearing the kids arguing in the background while you transcribe, such distractions will have an impact on your productivity, and hence your income.
How self motivated are you? Can you work well without direct supervision?
This is one of the biggest pitfalls of working at home. With no supervisor around to see what you're doing, it's easy to let home life get in the way of working. You can't allow this to happen. Medical transcription is typically paid on production, not hourly. You don't work, you don't get paid.
Also talk to your family about what you want to do. I can tell you from personal experience that not everyone will respect a work at home job as a real one. I was asked for 3 years by my mother-in-law when I was going to get a job when I worked as a medical transcriptionist. That it could be a real job was a hard fact for her to absorb because when she had stayed at home the only work she did was volunteer work.
Do you have or can you get high speed internet? More and more companies are having transcriptionists download the dictation off the internet rather than telephone lines, and this requires a high speed connection.
You should also be aware of potential future developments in technology that will impact the medical transcription industry. While many fear that voice recognition will do away with the need for transcriptionists, so far it is not nearly accurate enough, takes too long to train the software for the taste of many doctors, and will still need to be checked by a human due to the many similar sounding terms used in medicine.
Some companies are already hiring medical transcription editors to review transcripts created by voice recognition software.
And of course, you do have the schools to consider. There's the need for it to have a good reputation with employers. If no one will hire you because they don't like the track record of the school, you've just wasted potentially a couple thousand dollars and months of your time.
Check the schools out. Make sure that they have a solid reputation with employers. Some are partnered with potential employers, which can mean that students who do well enough have a better shot at available jobs.
Cost matters to pretty much everyone, and it's hard to find financial aid for most online medical transcription programs. But many will have payment plans, so you can find something that will work with your budget.
As a work at home career, medical transcription is a pretty good one. It's future is as yet promising, despite the fears new technologies generate, and despite outsourcing. The pay is good, the hours generally flexible. It's not a bad deal.
Both Connie Limon & Stephanie Foster are contributors for EditorialToday. The above articles have been edited for relevancy and timeliness. All write-ups, reviews, tips and guides published by EditorialToday.com and its partners or affiliates are for informational purposes only. They should not be used for any legal or any other type of advice. We do not endorse any author, contributor, writer or article posted by our team.
Stephanie Foster has sinced written about articles on various topics from Credit Cards, Shopping and Pets. Stephanie Foster is a former medical transcriptionist and runs
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