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A word from our editor...
The standard documentation options in Electronic Health Records (EHRs)-templates, point-and-click windows, and free-text typing-oppose the physician's workflow and traditional clinical documentation. First, templates cannot encompass every type of patient-encounter scenario. Second, structured templates and point-and-click documentation typically do not incorporate the physician's whole account of the medical encounter.
Medical transcription supports the capture of the clinical narrative, which is the clinical documentation in the physician's own words. The clinical narrative is a first-person view of the patient's medical encounter. It is both expressive and contextual, which is difficult to replicate with most EHR documentation options. Medical transcription provides the full and meaningful clinical documentation option that many physicians want in an EHR.
In addition, medical transcription is also a highly accommodating documentation method for physicians. It enables the physician to dictate using a cell phone, hand-held digital recorder, or using a traditional telephone. The mobile dictation options associated with medical transcription enables the physician to document the clinical encounter, without being tied to the EHR. Since dictation is a faster and easier clinical documentation option, it also reduces the time physicians spend documenting in the EHR.
Medical transcription makes the patient's record in the EHR more complete. If medical records are more complete, then the quality of care and patient safety can be improved, while the likelihood of adverse medical effects can be decreased. Some post-implementation reviews of EHRs have found that the use of cookie-cutter templates and point-and-click documentation, which both lack individuality, can produce incomplete clinical documentation for the patient.
The use of dictation and medical transcription with an EHR may provide the consummate model of clinical documentation for many physicians. And, it can be a very important contributor to a more complete patient record, which is something all of healthcare is striving towards.
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