If your health record misses out to mention one of your allergies, the next visit to the hospital could be fatal for you. Who do you blame for the error? The doctor who mumbled you allergies while recording the information, the background noise in the audio, the transcriptionist who couldn’t bother comprehending it, or the reviewer who cared less? Digital transcription is not about blind transcription but transcription with care. The most casual mistake by the transcriptionist can go on to impact the safety of a patient somewhere. That’s the reason why the overall quality goal in the profession is 98 percent and the goal with respect to critical errors is 100 percent. These goals are definitely high, and they need to be so.
Let’s look at the categories of digital transcription errors as identified by the Association for Healthcare Documentation Integrity (AHDI).
Critical errors: Incorrect names of tests or medicines, incorrect lab values or medicine dosage, omitted dictation, or incorrect information on patient identification lead to critical errors.
Major errors: These errors comprise of incorrect spelling of medical terms, incorrect verbiage, inappropriate flagging, or protocol failures.
Minor errors: The areas of improvement in the medical record are indicated by the minor errors.
As a transcriptionist, you may come across instances where the quality of audio recording is so poor that it is difficult to make any sense of it. Now, some transcriptionists make assumptions about the information or omit the part from the transcribed text. This leads to critical errors. If you cannot comprehend something, flag the part in the document. Flagging, however, should be done responsibly. It should not be done to shirk work. Remember, as a digital transcriptionist, you have a big responsibility on your shoulders. You inability to fulfill it will not only affect your career but also the health of several people.