08/28/2017
Skimming Your Transcription
One of the biggest temptations I have faced as a provider has been to skim over my transcribed dictations and assume they were fine. This could be especially tempting on those discharge summaries that came back for my review after a weekend off; the patient was stable at discharge, and there were likely few errors that needed to be fixed anyway.
Until the time that I received a text from my boss on my day off to please review a specific chart. The patient was back in the Emergency Department with the same problem and they had not been taking any of their prescribed discharge medications. Guess what was left off of the discharge summary that I skimmed over - the discharge medications. The information was easily tracked down in the electronic medical record, but I could have saved several people headaches and more work had I paid more attention.
What I needed was someone to look over my shoulder and notice when things were missing - before it became a patient care issue. At the time, we were using a corporate digital dictation system that was in the process of learning each individual user. We had been building our profiles for months and there were still a lot of errors making their way through to the final document. Transcriptionists were reviewing the documents, but only for errors in clarity as they were expected to be much more rapid in reviewing than in transcribing as was done in the past.
A well-trained transcriptionist, especially one familiar with a particular group or provider, will be able to catch when sections of a document are missing, which can be due to an overworked provider or an error in the capture of the dictation. Receiving an edited transcription is much easier to read (or skim!) and more likely to be accurate.
