The Role of Medical Transcriptionists in Producing High-Quality Documentation.
This study aimed to investigate the quality-assurance work conducted by medical transcriptionists in the production of medical records, and the implications of these findings when designing a structured electronic patient record (EPR) system in which physicians are supposed to write documentation themselves. Both qualitative and quantitative methods were applied. Qualitative data were collected through informal discussions and focus-group interviews. Quantitative data were collected through the medical transcriptionists' daily recordings of their quality-assurance work. The results show the many essential quality-assurance tasks conducted by medical transcriptionists and the extent of this work. Each medical transcriptionist performs an average of more than six corrections per day, and approximately one of three dictations are corrected. We suggest that these correction and quality-assurance tasks need to be compensated for when designing and developing new structured EPRs. Some quality-assurance tasks may also advantageously be performed by secretaries in the future.
Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway.
Monika A
MA
Johansen
Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway.
Åse-Merete
ÅM
Pedersen
Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway.
Gunnar
G
Ellingsen
D000068598:Data Accuracy; D004282:Documentation / Q000592:standards* / Q000706:statistics & numerical data; D057286:Electronic Health Records / Q000592:standards*; D062527:Meaningful Use / Q000592:standards / Q000706:statistics & numerical data; D008499:Medical Records / Q000592:standards* / Q000706:statistics & numerical data*; D009664:Norway; D011361:Professional Competence / Q000592:standards / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000379:methods*