The Health Insurance Portability and Accountability Act HIPAA prescribes a set of rules for health care specialists and institutions to follow in recording the services and products that they have given to their patients and to ensure that in the process of medical billing, accuracy of information is delivered and the privacy of the patient is guarded. In 2005, all health care specialists and institutions were required to follow the guidelines as set by the HIPAA in submitting their claims in order that such claims should be entertained.
Since then, the profession of medical transcription was born. Whenever a health care specialist conducts consultations with or other services for patients who are insured, they normally have the results of the process marked down on the patients records. Within the guidelines issued by the HIPAA, this procedure has been modified. Today doctors attending to insured patients are obliged to dictate on a recorder the all the details of the consultation or proceeding. The data to be included on the recording will vary according to the type of proceeding that is to be recorded.
For medical transcription of consultations the information contained starts with the date of the consultation or procedure, the name of the patient, the patient number, the name of the doctor, and any referring doctor as well. This is followed by a brief statement of any background of the patient or other circumstances that the doctor finds relevant to the process on hand. The doctor then records his initial diagnosis of the patient’s ailment. He then mentions any laboratory tests that the patient was made to undergo as well as the results of each test. Finally, the doctor mentions his final diagnosis, as well as any medical prescriptions and recommendations that were given to the patient.
For medical transcription of medical procedures performed, the details of the actions performed during the procedure need to be mentioned as well as the result of the procedure. This is then followed by any medications prescribed and recommendations made by the doctor.
The task of the medical transcription is to transpose the voice recording into a transcript that has a standard format. It is this transcript that will form the basis of any claims to be submitted to insurance companies. The job of the medical transcription is doubly more difficult than that of the medical encoder. Besides having to have a very sensitive ear, the he needs to be well versed in the general terminologies of medical science as well as the specific names used in the particular branch of medicine that the consultation or procedure belongs.
Not all voice recordings done by doctors are clearly recorded. There are recordings that are faint or marred by background noises or the doctor’s tendency to eat up some of the common medical terms. Some doctors also tend to slur over phrases that are common usage in the type of consultation or procedure being recorded. In addition, Doctors who are not native English speakers will tend to have an un-understandable pronunciation.
The medical transcription has to cope with and surpass all the shortcomings of the recording in order to produce a perfect transcription of the voice recording, containing all the details mentioned by the doctor.