The Medical Transcriptionist’s Role with the Healthcare Record

nThe healthcare record is:nn• Chronologicaln• Documents of a patient’s initial databasen• Initial evaluationn• Identified problems and needsn• Objectives of caren• Prescribed treatmentn• ResultsnnThe 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.nnThe 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.nnA 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.nnWhat is the purpose of a healthcare record?nnIt 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.nnThe healthcare record is kept for legal protection for:nn• The medical care facilityn• The patientn• The staffn• The physiciannnThe healthcare record can be used for:nn• Researchn• Compiling statisticsn• Evaluation of healthcare deliverynnThe healthcare record originates:nn• In the admissions department of hospitalsn• Outpatient registration n• Emergency departmentn• Private physician facilities reception areannThe major role of all departments of healthcare record origins is to:nn• Collect patient identification and demographic informationn• Correct spelling of patient’s legal name and birth date is criticalnnThe 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. nnnnThis article is FREE to publish with the resource box.nn© 2007 Connie Limon All Rights Reserved