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Quality Assurance for Medical Transcription

AHDI Position Statement


This Statement on Quality Assurance reflects goals that transcriptionists, transcription services, and healthcare providers should, in AHDI's view, strive to achieve. The standards expressed herein are ideals; it may not be reasonable or possible for every competent transcriptionist to meet these standards in every instance. Moreover, the ability to conduct extensive ongoing monitoring is somewhat dependent on an organization's resources, and, as noted herein, the ability to generate accurate transcription depends, in large part, on the quality of the source document or tape.

Position

AHDI believes that transcribed documents are a vital and necessary component to the healthcare record. Transcription accuracy therefore should be monitored regularly to ensure quality documentation and to ensure that medical transcriptionist professionals receive timely and consistent feedback. Attention to quality should reflect an understanding that even minor errors in the record potentially can create health risks for a patient, and can diminish the credibility and perceived competence of the healthcare provider.

Rationale

With the number of malpractice lawsuits in the United States increasing dramatically each year, those involved in the documentation of patient care must consider the correlation of that documentation to compromised care and malpractice litigation. While the most fundamental reason for supporting and promoting quality documentation is to ensure continuity of care, it is important to recognize that errors in the healthcare record have the potential to put at risk the patient, the healthcare provider, or both. Errors in the patient record, whether major or minor, medical or grammatical, are potentially useful to plaintiff attorneys in threatened or actual litigation against healthcare facilities and providers.

The patient record is the only real evidence of care provision in any healthcare facility. To ensure an accurate and complete record, all items and services should be documented by the healthcare professional at the time of care. More generally, accurate and complete healthcare documentation involves a partnership between the patient, the healthcare provider and the documentation team.

A valid quality assurance process ensures that medical transcription practices are as consistent and accurate as possible. Whether an MT is the transcriptionist of the document or is an editor of the same, human judgment will always be involved in this process. The degree of accuracy and consistency that can be achieved depends on the experience and skill of the MT coupled with the acoustical quality of the dictation and the organization, focus, and language proficiency of the author.

A skilled medical transcriptionist will have a broad knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values, in addition to proficiency in English usage, grammar, punctuation, and style. A seasoned medical transcriptionist also should possess refined intuitive skills and sound judgment.

Principles of Quality

When a document is reviewed (i.e., audited) for quality, key principles in establishing quality assurance criteria for that document are:

  • The transcribed report should be reviewed against the actual dictation. Reading the report without listening to the dictation does not provide an accurate comparison of the transcription to the dictation.
  • The review should apply industry-specific standards as provided by current resources and references. When evaluating style, punctuation, or grammar, The AAMT Book of Style is the industry standard.
  • The review should encompass attention to risk management issues and the documentation standards of accreditation and healthcare compliance agencies.
  • Accuracy scores (ratings) should be quantified with the use of a numeric calculation that weights varying degrees of error against the length of the report. AHDI recommends the following quality goals: 100% accuracy with respect to critical errors; 98% accuracy with respect to major errors; and 98% accuracy with respect to all errors in the report, including minor errors (see below for definitions of "critical," "major," and "minor" errors).
  • The reviewer (or the review process) should provide timely and consistent feedback to the medical transcriptionist in order to eliminate repetition of errors.
  • All measurements, standards, and benchmarks should be disclosed to the medical transcriptionist and should be set forth in written guidelines by the healthcare provider or transcription service.

Application of Principles

The application of these principles and the development of a quality assurance program that incorporates them should be set by organizational policy. AHDI recommends the following considerations in doing so:

Frequency: Reports transcribed by medical transcriptionists who are new to an organization should undergo review on a regular basis until competency and judgment have been consistently demonstrated. At that time, random review by periodic sampling of transcribed reports should be performed to ensure ongoing compliance with quality standards. AHDI recommends selecting a 3% to 5% sampling of documents for the period being reviewed, although the sample could be larger or smaller depending on (a) whether there have been quality or accuracy issues with the particular transcriptionist in the past; and (b) how much time has elapsed since the transcriptionist's most recent review.

Delineation: Clear qualification and quantification of errors should be established for the purposes of document evaluation. For the purposes of definition, a critical error is one that potentially could compromise continuity of care, such as medical word misuse or omitted dictation. A major error is one that compromises the integrity of the document without risk to patient care, such as misspellings, most demographics errors, and formatting errors. A minor error is one that compromises neither patient care nor document integrity but represents an area of recommended improvement to the transcriptionist, such as capitalization, punctuation, and other minor style and grammar errors.

Accuracy: While transcriptionists should strive to ensure that every document is 100% accurate prior to delivery to the healthcare provider, as noted above it is AHDI's recommendation that organizations set the following goals for transcriptionists: at least 98% accuracy with respect to all errors, at least 98% accuracy with respect to major errors, and 100% accuracy with respect to critical errors. It is important to reiterate that hitting these targets should be the goal in transitioning a transcriptionist through any comprehensive quality assurance program. These targets are not likely to be achieved overnight, and they should not be used to penalize a relatively new or inexperienced transcriptionist, or even an experienced transcriptionist who is new to the quality assurance process or in a new work setting. Rather, these goals should be established as the standard to which all transcriptionists ultimately will be held. It also should be understood that despite every attempt to develop an objective evaluative tool for QA, review is inherently subjective and some flexibility in that regard should be incorporated into the process. Also, some allowance should be made in situations where the dictated tape or source document is of poor quality. Finally, all organizations must recognize the inherent trade-off between speed and accuracy. To the extent that an organization sets productivity standards that are unreasonable, or that require constant production with little time for thought or research, accuracy is certain to suffer. It would not be fair or appropriate to hold transcriptionists to the above-stated accuracy goals in that kind of environment.

Purpose: Ongoing feedback, education, and performance improvement should be the goal of any quality assurance program. The scope of the program should not be limited to merely the correction of errors, but should focus on developing a transcriptionist's experienced judgment, including the ability to discern client/chart-ready documents from those that could benefit from additional review. Attention to quality must also include a commitment to the ongoing professional development and continuing education of the medical transcriptionist as a means of ensuring overall continuous quality improvement.

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