The Role of Medical Records - Essay Example

Short Book Report Today, human race has advanced radically, and it has altered lives of millions of people around the globe. In the antiquity, people used to prefer homeopathy; however, scientific innovations resulted in domination of allopathic healthcare, which is now considered a basic component of a society. A number of steps are being taken by governmental, as well as, nongovernmental organizations to ensure public healthcare in developed, as well as, developing countries. In this regard, it is very imperative that healthcare system should be managed properly and effectively, in order to provide high-quality services to patients, as well as, physicians and experts. In brief, system information management is one of the common factors that play a crucial role in the evaluation of effectiveness of healthcare services. Specifically, proper recording, arrangement, and management of medical records of individuals is an important issue that has confronted a great deal of criticism since the beginning of public healthcare. It is noted by the experts that performance of healthcare professionals had an adverse impact due to unreadable and scrawled medical records, or due to mismanagement of this valuable resources. In other words, it is very essential that a physician or medical expert should be provided with accurate and updated version of medical records, in order to treat him/her effectively. Therefore, healthcare professionals have felt an urgent need of proper management and recording of medical records and transcriptions that may left an adverse impact on lives of their patients, as well as, their personal lives. Since the demand of documentation of medical records has increased rapidly, services of medical transcriptions are now being outsourced in a number of countries, which has resulted in a number of benefits, as well as, drawbacks. Briefly, confidentiality and accuracy are two of the important factors that cannot be exaggerated, as they provide a supportive environment to healthcare professionals by the provision of accurate and effective tools for reconstruction of previous medical events. In this regard, it is imperative that information in the medical records should be kept confidential, which is one of the most important codes of medical ethics. In the year 1996, the Health Insurance Portability and Accountability Act began to influence the healthcare profession, and still, studies are being carried out to analyze its impact over this area of expertise. Studies have indicated that breach and violation of already mentioned code of medical ethics has resulted in humiliation of the profession. Thus, medical transcriptionists play a crucial and vital role in improvement of management and recording of medical records. In this regard, HIPAA has formulated a number of rules and regulations that bound a medical transcriptionist to act accordingly. In brief, confidentiality is one of the imperative factors that should be considered by an MT, and proper steps, such as login procedures, implementation of information security policy, etc. should be taken to ensure confidentiality of the medical records. It is indicated by researches that different roles are played by MTs in different situations, as a focused transcription is usually recorded in a physician’s office, which spotlights medical histories and referral letters of patients. On the other hand, extensive medical procedures and reports are focused in hospital transcriptions. Besides different roles, similar obstacles are confronted by medical transcriptionists, which should be dealt in an effective manner. Medical language and its notations are considered one of the most difficult by most of the MTs and healthcare professionals. In this regard, an MT should be aware of wide range of dialects that can be used by physicians, as accuracy of transcription will be the deciding factor for future opportunities related to the field. As earlier mentioned in the report that accuracy and confidentiality are the two important factors that should be considered by MTs, it is imperative that intimate medical information should be transcribed personally and proper significance should be given to sensitive status of a patient’s record. In other words, MTs are considered a vital component of healthcare profession, and thus, respect is one of the basic features that are required by privileged nature of medical records. It is observed by experts that a number of obstacles are confronted by MTs during their transcribing period. One of the significant factors is process of listening, which decides the extent of accuracy in the transcription. Past records have shown that listening is often regarded as hearing, which results in a number of complications and discrepancies in the medical records of patients. In this regard, effective combination of concentration and communication skills may result in long-term maintenance of professionalism required from medical transcriptionists. It is observed that medical transcriptions are often considered as a commercialized work, rather than a duty that should be completed with quality and accuracy. In other words, outsourcing of MTs has commercialized the nature of abovementioned process of managing medical records. In this regard, the process should not be taken as a source of income, but as a duty, which requires accuracy, quality, confidentiality, rather than quantity with blunders. In other words, proper steps should be taken by medical transcriptionists to continue their learning process, in order to provide a high quality and accurate medical transcription. Moreover, it is very rare that physicians have a major in English language, and therefore, it is the responsibility of transcriptionists to revise the matter in an intellectual manner, rather than leveling the grammar. In this regard, it is very imperative that individuals should be well aware of medical terms, dialects, notations, and challenges related to the field of medicine. However, studies have indicated that a number of medical transcriptionists alter the medical terms as per their understanding, which often results in misconceptions for physicians, and may be harmful for the patients. Experts have preferred flagging of medical reports, rather than personal alteration by transcriptionists. Indemnification clauses is another major article that should be added by all the freelance medical transcriptionists, in order to avoid any conflicts related to lawsuits, which may create any kind of liability issues for them. A number of individuals do not consider this an important issue, and therefore, it is important that proper guidelines should be provided to transcriptionists. In summary, medical transcriptionists play a vital and crucial role in the healthcare profession, and have an impact on physicians, as well as, patients. Conclusively, paper has tried to understand and discuss different aspects of medical transcription that is one of the important sectors of healthcare profession. It is hoped that the report will be beneficial for the students, teachers, experts, and nonprofessionals in better understanding of the topic. Works Cited Donna Avila. The Independent Medical Transcriptionist. Lippincott Williams & Wilkins, 2002. Read More