From a post by Gary Patterson of Pearce, Patterson and Associates, Inc.
I’ve got a transcriptionist that does reports from her doctor’s short-hand messages. One doctor reads a two page SOAP note in less than a minute. They have been working together so long that they have built a trust. She knows what he’s saying…even when he doesn’t say it.
In another case, I once had a doctor dictating a particularly long CT of the abdomen and pelvis on a 53 year old woman. Everything was going well until I heard the doctor say that the prostate was swollen. Now, even though I’m not as well trained as the doctor, there seemed to be something obviously out of place here. I finished the report and sent it back to the doctor suggesting that he give it another look. It turns out that I was correct. The doctor is very courteous when dictating, stopping and starting the microphone to keep us from having to sit through long patches while he’s thinking. During one such break, he became distracted by a cell phone call. When he came back to the file, he thought he was done with one report and set it aside. He’s picked up the jacket of a 72 year old male and finished the dictation.
What do these two anecdotes have in common? In both cases the transcriptionist caught inconsistencies, brought them to the attention of the doctor and they were fixed before they ever hit the floor. Transcription acted as a first line of defense for errors in the documentation process.
The old adage that everything begins and ends with the doctor is a thing of the past. These days, the doctor is the point-man of a team of medical experts dedicated to providing the best medical care possible. The hidden key to the successful team is communicating information to all parts in a timely manner so that everyone are working in concert towards the patient’s better health. It is crucial, therefore, that information is transferred accurately and in a timely manner. In some instances, seconds make the difference in life or death. Medical staff must take reports at face value. They don’t have time to question the validity of the information. The unfortunate part is that sometimes accuracy is sacrificed in the name of speed.
Doctors need to look at the transcriptionist as a valued member of the team providing a back-stop for their accuracy. I traditionally, have a good rapport with the doctor’s in my departments so when situations happen, we can get it straight. No feathers are ruffled by a report coming back to editing requesting more information or suggesting that the doctor take another look. I’m constantly amazed when I hear that the transcriptionist is considered a commodity. The hospital/doctor/facility are missing a great opportunity to include a valuable team member.
The point is that doctors, like everyone else, are not infallible. Mistakes are made. It’s the job of the team to catch them when they happen and correct them before they have an impact on patient health. The Medical Transcriptionist (MT) is at the center of the information flow and is in the best position to provide immediate feedback to the doctor. Experienced MTs who’ve spent a long time in this business are able to pick up on nuances and inconsistencies that rival that of a second opinion. MT’s and doctors alike need to recognize this symbiotic relationship and develop two-way relationships to pass information both ways.
Those institutions treating their transcription like a commodity, will get exactly that, a commodity. There are many companies that will type reports very cheaply. All they do is type what they hear. Nuances, abbreviating, short-hand are all beyond their comprehension. The really special ones do more than type, they become a valued team member on the front lines fighting errors and inaccuracies. When you come across one of them, or a company, with that ethos, grab them quickly and hold on tight. They are in short supply.
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