The Medical Transcriptionist's Role With The Healthcare Record

The healthcare record is:

• Chronological

• Documents of a patient's initial database

• Initial evaluation

• Identified problems and needs

• Objectives of care

• Prescribed treatment

• Results

The healthcare record belongs to the hospital, medical facility or office where it originated. It cannot be removed from the premises without a subpoena or court order. Although much of the healthcare record is maintained through computer software systems, most medical care facilities still maintain a “paper” healthcare record of some sort.

The healthcare record is maintained by the Health Information Department of hospitals and medical facilities and usually headed by a registered record administrator or an accredited record technician.

A former term for the healthcare record for over fifty years was “Medical Record.” The new term of healthcare record denotes both illness and wellness. The Medical Record Department name has also changed to Health Information Department.

What is the purpose of a healthcare record?

It is a measurement and documentation of care rendered in a medical facility. The healthcare record is used to plan, communicate and evaluate the quality of care given to each patient. It provides “proof” of work done for each patient. Documents are required to meet federal, state, and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) standards and regulations. In addition the documents contained in a healthcare record must meet regulations for reimbursement and third-party payer requirements.

The healthcare record is kept for legal protection for:

• The medical care facility

• The patient

• The staff

• The physician

The healthcare record can be used for:

• Research

• Compiling statistics

• Evaluation of healthcare delivery

The healthcare record originates:

• In the admissions department of hospitals

• Outpatient registration

• Emergency department

• Private physician facilities reception area

The major role of all departments of healthcare record origins is to:

• Collect patient identification and demographic information

• Correct spelling of patient’s legal name and birth date is critical

The information collected is used to assign healthcare record numbers and is maintained for the lifetime of the patient. It is vital that the medical transcriptionist transcribe the identification and demographic information concerning a patient with complete accuracy as well as all other physician dictated reports. A transcribed incorrect date of birth or patient number can produce chaos in the Health Information Department and throughout the medical facility.


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