Written by:

Jim Plewa

Chief Operating Officer CaseReader by DPR

Medical Transcriptions
Medical transcription is the art (and science) of capturing physicians dictated words in a report accurately, an increasingly important task when considering the growth of electronic health records across all medical practices in recent years.
by: Jim Plewa, Chief Operating Officer of CaseReader 2

Medical Transcriptions
The production of medical transcripts is a timeconsuming task but accuracy in a patients history is paramount, especially when more medical professionals across a variety of specialties will access the same report during their interactions with a patient.
by: Jim Plewa, Chief Operating Officer of CaseReader
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Medical Transcriptions
No longer are medical records simply tied to a single practice and,

therefore, medical transcription services are increasingly overwhelmed with requests for clear and accurate medical transcript production.
Many practices outsource this

work to those trained as medical language experts but this field of medical administration is also the focus of innovative voice recognition technology to aid in producing these medical transcripts.
by: Jim Plewa, Chief Operating Officer of CaseReader 4

Medical Transcriptions
A patients medical transcript will contain a wealth of information,

including their symptoms, medical history, family history, test results, details of prescriptions and procedures and a diagnosis.
Whenever a patient visits

their physician and undergoes an examination or spends time talking through their symptoms and/or progress the physician will make a record of the outcome of the visit.
by: Jim Plewa, Chief Operating Officer of CaseReader 5

Medical Transcriptions
Oftentimes, a physician uses a handheld voice recorder to dictate notes after the patient has left and these will be then be passed on to a medical transcriptionist.

by: Jim Plewa, Chief Operating Officer of CaseReader

Medical Transcriptions
Producing a medical transcript is not as simple as typing

out the words spoken by the physician as a patients report is considered a legal document and requires specific formatting.
Once the transcript is complete it is entered into the

patients file and can be called on in the future by the physician themselves or by another specialist treating the patient.

by: Jim Plewa, Chief Operating Officer of CaseReader

Medical Transcriptions
The correct formatting, review and editing of a medical

transcript is important as this not only makes it much faster for physicians reviewing the patients history, it also means that an improperly recorded medication is identified quickly and can be corrected to avert risk. review the transcript upon completion but, in practice, some physicians do not review these transcripts and they are marked instead as dictated but not read to signal that there may still be potential accuracy issues.

The physician providing the dictated notes is supposed to

by: Jim Plewa, Chief Operating Officer of CaseReader

Medical Transcriptions
Medical transcribers can also flag a transcript if they spot

inconsistencies in the report or if the words captured by the recorder were unrecognizable.

Slow, precise and concise speech is vital to helping a

transcriber produce accurate work and the same is true for voice recognition technology when dictating the names of medications, the procedure undertaken and the diagnosis.

by: Jim Plewa, Chief Operating Officer of CaseReader

Medical Transcriptions
Medical transcribers have to contend with regional and even national accents, rushed speech (particularly from Emergency Department physicians physician), mispronunciations and abbreviations of medical terminology, disordered speech when a physician recalls something out of the context of the current sentence, and even incorrect dosages or other errors.
by: Jim Plewa, Chief Operating Officer of CaseReader
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Medical Transcriptions
The transcriber must also make sure to check references

and the proper spelling of medical terminology and highlight any problems they see in the report for the physicians review. Medical transcriptionists need to constantly be updating their database of new medical equipment, drugs, devices and nomenclature in order to produce accurate reports and this is just one area where a centralized database available with voice recognition software is helpful.

by: Jim Plewa, Chief Operating Officer of CaseReader

11

Medical Transcriptions
Physicians looking for efficiencies can also improve the accuracy of their own dictation, produce clearer medical transcripts that are properly formatted and easy to review while reducing waittimes for outsourced medical transcription services by using medical speech-to-text voice recognition technology such as M*Modal Fluency.

by: Jim Plewa, Chief Operating Officer of CaseReader

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Medical Transcriptions
One solution CaseReader by DPR has embedded M*Modal voice recognition technology.
Within CaseReader Fluency is

utilized for navigation and dictation in a templated environment to produce timely and accurate clinical documentation.

by: Jim Plewa, Chief Operating Officer of CaseReader

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Medical Transcriptions
The all-software solution enhances

productivity and may increase revenue by ensuring accuracy and safety in patients medical transcripts.

Its seamless integration with the

ability to embedded images in the final report make CaseReader a valuable tool for radiologists and referring physicians.

by: Jim Plewa, Chief Operating Officer of CaseReader

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Medical Transcriptions
Written by:

Jim Plewa
Chief Operating Officer CaseReader

2400 Camino Ramon, Suite 125, San Ramon, CA 94583 925-327-0835 | info@casereader.com www.casereader.com Connect with CaseReader on:

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