1. Management
» Knows the institution's mission, vision, and values,
and communicates same to staff
» Communicates effectively (both orally and in writing)
with administrators, physicians, co-workers, and other healthcare
personnel when providing information and/or services
» Directs, monitors, evaluates, and makes recommendations
for continuous quality improvement
» Establishes a team-oriented, efficient, and effective
work environment
» handles difficult and sensitive situations tactfully
and responsibly
» prepares and analyzes department statistics as required
» identifies the need for, and negotiates appropriate
content of, contracts with employees, independent contractors,
and medical transcription services
2. Finance/Budget
» develops, implements, and manages a budget according
to institutional policies and procedures
» develops short- and long-range financial strategies
in concert with institutional mission, vision, and values
3. Human Resources
» complies with local, state, and federal employment
laws affecting employees and independent contractors
» complies with the Americans with Disabilities Act
(ADA)
» recruits, supervises, supports, and evaluates staff
» disciplines staff and participates in termination
when necessary
» promotes and provides opportunities for professional
development and continuing education
» identifies and appropriately resolves conflicts
» promotes and facilitates individual participation
toward group efforts and decisions
» elicits medical transcriptionist's input before making
decisions on purchasing equipment, educational products, and
reference materials
» provides appropriate orientation, job training, and
performance expectations
» verifies CMT status and other relevant credentials
of medical transcription staff
» performs the above in consultation and conjunction
with the organization's human resources department, as appropriate
or as required by the organization's policies.
4. Medical Transcription Practices
» Remains informed about new developments in medical
transcription technology, processes, styles, and practices
» When requested, listens to dictation and offers medical
transcriptionists editorial guidance, applying knowledge of
English and medical language, style, and practices
» Identifies the need for and facilitates continuing
education for staff
» identifies and provides appropriate resources for
staff efficiency
» Identifies, plans, develops, implements, and enforces
professional practice standards
» Assigns work according to department policies
» Researches and identifies necessary dictation and
transcription equipment
» Reviews and makes recommendations for leases and service
contracts for dictation and transcription equipment
» Uses technology to maximize efficiency, effectiveness,
and safety of office environment
» Knows how to operate dictation and transcription equipment
and troubleshoots problems
» Assesses condition of equipment and furnishings to
identify need for replacement or repair
» Maintains systems security
» Acts as a communication link between medical transcriptionists
and dictation originators, creating a path for two-way feedback
5. Healthcare Documentation and Risk Management
» Develops and maintains policies and procedures to
ensure compliance with local, state, and federal laws regarding
the healthcare record
» Identifies potential risk management situations and
reports to appropriate authority
» Develops and administers procedures for correction
of transcribed medical documents
» Ensures compliance with facility's confidentiality
and release of information policies and procedures
» Recognizes, interprets, and evaluates inconsistencies,
discrepancies, and inaccuracies in medical dictation, and
appropriately clarifies and/or reports them
» Ensures compliance with applicable standards for transcription
departments established by the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO), ASTM, HL7, the Centers
for Medicare and Medicaid Services (CMS), and other appropriate
standards-setting bodies
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. AAMT 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. AAMT 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. AAMT 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 AAMT'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.
Be it therefore declared that
each medical transcriptionist has the following rights:
1. The right to an appropriate job classification and pay
level appropriate to one's abilities, limitations, and responsibilities.
2. The right to full disclosure of the basis on which pay
is determined.
3. The right to fair pay, including overtime pay, and to benefits,
including sick pay, holiday pay, vacation pay, and health
insurance.
4. The right to nondiscrimination on any basis, including
gender, age, disability, race, religion, sexual orientation,
and ethnicity.
5. The right to a safe work environment that promotes prevention,
identification, and treatment of work-related injuries and
disabilities.
6. The right to communicate with others in order to assist
or be assisted, including feedback on performance and inquiries
made regarding dictation or transcription.
7. The right to edit dictation as necessary and appropriate
to produce a clear, concise, and accurate document, correcting
grammar, punctuation, and spelling, drawing attention to inaccuracies,
inconsistencies, incomprehensible dictation, and potential
risk management concerns.
8. The right to professional resources (print, video, audio,
electronic) that facilitate the preparation of accurate and
complete documents.
9. The right to environmental resources (space, equipment,
furniture, lighting, and supplies) that promote the efficient
and effective accomplishment of responsibilities.
10. The right to professional development and continuing education
opportunities.
11. The right to professional association membership and participation.
12. The right to participate in the development of, to be
informed of, and to adopt professional guidelines and standards
for medical transcription.
13. The right to respect and recognition as a professional,
as a medical language specialist, and, for those who have
earned the designation, as a certified medical transcriptionist
(CMT).
14. The right to participate fully as a healthcare professional
in the preparation of patient care documentation in order
to enhance the quality of that documentation and thereby the
quality of patient care.
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