US HEALTHCARE

Objectives

Know the Healthcare Industry and Process What is Medical Transcription? Medical Transcription Process Different types of Patients Different Providers Various Reports Skill Set to perform Medical Transcription Scope and Future of Medical Transcription

US HEALTHCARE PROCESS

Appointment

Registration

Financial Discussion

Encounter

Billing Insurance

Claims Adjudication

Payment or No Payment

Settling of Patient’s Account

Collecting Balance from Patient

Insurance

BriefTake an appointment

Register oneself in Provider’s office and their software

Do a finance discussion for the payment

Meet the Provider for treatment

Generate Bill to be sent to Insurance

Let the bill be processed at the insurance end with the details sent resulting in either payment or denial

Settling of the patient’s accounts as per the Insurance follow up

Balance billing to the patient

Collect balance amount and reschedule for next appointment

Medical Transcription:

Medical transcription is an allied health profession, which deals in the process of converting pre recorded providers voice files into text files/documents. These files after conversion are called as transcribed reports or sheets.

VOICE FILEVOICE FILE MEDICAL TRANSCRIPTIONISTMEDICAL TRANSCRIPTIONIST TRANSCRIBED SHEET /

MEDICAL RECORDSTRANSCRIBED SHEET / MEDICAL RECORDS

Medical Transcription Process

When any patient visits a doctor, the latter spends time with the former discussing his/her medical problems, including history and/or problems. The doctor performs a physical examination and may request various laboratory or diagnostic studies; will make a diagnosis or differential diagnoses, then decides on a plan of treatment for the patient, which is discussed and explained to the patient, with instructions provided. After the patient leaves the office, the doctor uses a voice-recording device to record the information about the patient encounter. This information may be recorded into a hand-held cassette recorder or into a regular telephone, dialed into a central server located in the hospital or transcription service office, which will 'hold' the report for the transcriptionist. This report is then accessed by a medical transcriptionist. It is received as a voice file or cassette recording. In turn the transcriptionist listens to the dictation and transcribes it into the required format for the medical record, and of which this medical record is considered a legal document. The next time the patient visits the doctor, the doctor will call for the medical record or the patient's entire chart, which will contain all reports from previous encounters.

Types of Patients:

Types of Physicians:

Types of Medical Reports (Major Ones):

History and Physical (H&P): This report is usually dictated by the admitting physician or resident when a patient is admitted to the hospital. It usually begins with a chief complaint. The “history” includes a history of the present illness, past medical history, social history, and family medical history. Smoking can go under the heading of either Social History or Habits. There is usually a review of systems and a complete physical examination from head to toe. The report usually ends with an admission diagnosis and a plan for the patient’s treatment.

Consultation (Consult): This report is usually dictated by a physician to whom the admitting physician has referred the patient. Therefore, the consulting physician is usually a specialist in an area other than the admitting physician. Sometimes consultations are requested for second opinions. Consultation reports usually include a brief history of the patient’s illness and a specific physical exam depending on the particular type of consultation requested. The report may also include laboratory or x-ray findings. The report usually ends with the consulting physician’s impression and plan, and sometimes a comment from the consulting physician thanking the admitting physician for the referral.

Types Of Medical Reports (Major Ones) Contd…..

Operative Report(OP): This report is dictated by the operating physician and contains detailed information regarding an operative procedure. Included in this report are preoperative and postoperative diagnoses, the type of surgery or surgeries that were performed, the names of the surgeon(s) and attending nursing staff, the type of anesthesia and the name of the anesthesiologist, and a detailed description of the operative procedure itself. Depending on the operative procedure, information regarding instrument counts, sponge counts and blood loss are also dictated. Often the report will end with disposition or where the patient was transferred when he left the operating room (usually recovery room) and the condition of the patient at the time of transfer.

Discharge Summary (DS): This report is dictated by the admitting physician at the end of the patient’s stay in the hospital. It includes a summary of everything that occurred from admission to discharge, including laboratory data, x-ray data, and pertinent physical findings throughout the hospital course. The report usually ends with the discharge diagnosis and a detailed plan for the patient. If the patient is transferred to another institution (such as a nursing or other hospital), the name of the report is usually changed from discharge summary to transfer summary. If the patient has expired (died) during the hospital stay, the report is usually called a death summary.

Types Of Medical Reports (Major Ones) Contd…..

Radiology Report: This report is dictated by the radiologist upon completion of a diagnostic procedure and includes the radiologist’s findings and impression. Examples of radiology reports are x-rays, CT scans, MRI scans, nuclear medicine procedures and fluoroscopic studies.

Pathology Report: This report is dictated by a pathologist and describes findings of a tissue sample. The focus of the report is on the microscopic findings and the pathological diagnosis of the sample.

Laboratory Report: This report describes findings of examinations of bodily fluids such as blood levels and urinalysis. Laboratory reports are rarely dictated separately but are often included inside the H&P, consultation or discharge summary.

Miscellaneous Reports: Other miscellaneous hospital reports include cardiac catheterizations, electrophysiology studies, phacoemulsification, autopsies and psychological assessments.

SKILL SETS REQUIRED TO PEFORM MEDICAL TRANSCRIPTION

1. Strong English Grammar.

2. Compelling interest in the medical field.

3. Superior research skills.

4. Competent use of computer.

5. Keen listening skills.

6. Fine attention to details.

7. Commitment to lifelong learning.

8. Ability to sit and concentrate for long periods of time.

FUTURE AND SCOPE OF MEDICAL TRANSCRIPTION

• Bureau of Labor Statistics predicts a need for 5.3 million healthcare workers.

• Supply not keeping up with demand.

• Aging population will put increasing pressure on the unprepared healthcare system in US

FUTURE IS BRIGHT- for professionals looking for a careers and not just a job.

- for professionals willing to commit to lifelong learning.

- for professionals willing to embrace standards and credentialing

Thank You