CPR - Computer-based patient record
Electronic signature - Electronic view/editing followed by electronic authentication (signature) by the provider.
Fat client /Thin client - Fat client refers to the PCs that require software to access the transcription systems. Thin client refers to browser-based access to the transcription systems.
In-house - The process by which a healthcare organization employs staff to perform all aspects of medical record documentation. This process often involves dictation equipment, updates/maintenance of equipment, as well as transcription equipment.
Linecounting - Units or measurements that can be clearly and consistently verified within medical transcription include:
- Character Any letter, number, symbol, or function key necessary for the final appearance and content of a document, including the spacebar, carriage return, underscore, bold, and any character contained within a macro, header, or footer. AAMT prefers the character as the basic unit of measure, where such measures are appropriate.
- Word Five (5) characters. Total character count can be converted to words by dividing character count by the specified number of characters in a word, in this instance 5.
- Line Example would be sixty-five (65) characters. The total number of lines for reporting purposes is determined by dividing the total characters by the specified number of characters in a line, in this instance 65. Margins may vary, resulting in gross lines of varying numbers of characters. (See gross line of transcription below).
Measurement - Comments below demonstrate the inadequacies of using units other than Linecounting to measure medical transcription services.
- Keystroke The strike of a single key. Measures “input” only, reducing a macro to entry strokes rather than meaningful output terms.
- Gross line of transcription A line of print with one or more printed characters. Obsolete and inconsistent; a gross line may consist of a single character or as many characters as will fit between the margins (See “line” above). Gross lines may be manipulated by margins and font sizes.
- Minute of dictation A measure of access time to a dictation unit or system. The definition of access time may vary among units/systems, so that a minute of dictation is not consistent among units/systems.
- Page of transcription One side of any size sheet of paper with one or more printed characters on it. Inconsistent since the paper can be of any size, with any number of printed characters.
Medical transcriptionist, acronym MT (medical language specialist) - The title assigned to the individual who has obtained the education necessary to translate medical dictation into meaningful legible communication documenting patient care.
Outsourcing - The process by which a healthcare organization contracts with a medical transcription company to integrate one of its biggest headaches, included but not limited to staff integration, benefits, equipment, technology, updates and maintenance.
Overflow - Typical term used by transcription vendors to classify accounts that contract to transcribe volume that the in-house staff cannot get done.
Quality - A valid quality assurance process to ensure that medical transcription practices are as consistent and accurate as possible. Clear qualification and quantification of errors should be established for the purposes of document evaluation. Accuracy: Medical transcriptionists should strive to ensure that every document is accurate prior to delivery to the healthcare provider. It is the industry recommendation that goals for the medical transcriptionist reflect 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.
Routing/Distribution - The mechanism customized to deliver transcribed documents. Routing/distribution methods include printing to a printer (TCP/IP), e-mail (encrypted), fax, batch (sent in batches at periodic intervals), document upload.
Turnaround time, acronym TAT - The measurement between the time the dictation is closed (ready for transcription) and the time the medical transcriptionist completes the dictation.
Worktype (WT) - The type of report dictated, i.e. history and physical, consultation, operative report, progress note, etc. WTs typically have a number assigned to them.