Chapter 15 Notes: Medical Documents

What is the new trend in medical transcription? How are digital images integrated directly into the transcribed record? What are the benefits of this new trend in medical transcription?

1) A new trend in medical transcription is the integration of digital images directly into the transcribed record. The response to inputting digital images (photgraphs, scans, and radiographs) has been positive from both the local health care community and patients themselves. This is attributed to easier understanding of a picture by patients and more precise presentation using both pictures and written text to medical professionals 2) The tools required for integrating digital images into word processing programs is already available to most medical transcriptionists in their current Microsoft Word software packages. They only have to obtain the digital images from their provider-employer. If the transcribed record is included in the EHR, digital images can be attached, allowing other providers to view, enlarge, and manipulate the images at will

What is the impact of electronic health records on medical transcription?

1) Clinics using electronic medical records (EMR) rather than paper-based medical records may delegate much of the MT's responsibility to other medical personnel. For example, the medical assistant may record directly into the EMR the reason for the visit, medications the patient is currently taking, including over-the-counter and herbal products; height and weight; vital signs; and any observations. The provider, using the computer, has access to the entire patient medical record and may call up test results, various images, diagnoses, and treatment plans for verification or comparison. The provider may add to the EMR document by directly keying in chart notes or by dictating to a digital recording system or may use voice recognition software. The provider may complete and transmit prescriptions directly to a pharmacy or forward all or part of the medical record to a referring provider 2) Each entry into the EMR is automatically date and time stamped, which facilitates documentation and tracking of patient care and outcomes. The EMR provides easy access to quickly locate accurate and readily usable information about the patient at the point of care. EMR are much more efficient in the clinical decision-making process than the old cumbersome paper-based patient records. EMR may be sent to all medical personnel involved in the care of a patient in a matter of seconds. 3) We have covered the process of changeover to a computerized system in the medical clinic in chapter 10, but we have not covered the process of the physical transition from existing paper medical records to electronic health records. Two issues must be resolved: How much of the paper chart do we convert to a digital format and how do we make the majority of the existing clinical history available to the physician? Several options are available: 3a) All patient charts are scanned into the EMR system. This choice is the most attractive option, but it is also the most costly. Although the basic scanning can be performed by a relatively unskilled worker, a trained medical professional must file the data in the appropriate category of the new medical record so that it can be readily located by the medical provider 3b) Partial scanning of patient charts: Charts are pulled for existing patients scheduled for the coming week and only the clinically pertinent information from the past three to six visits as identified by the medical provider are scanned and filed in the new system. This process is repeated until partial paper records for all patients are included in the EHR system. This approach requires that paper records be actively retained for a period before they are archived 3c) Do not scan any old information: Develop an EHR record for all patients from a given date and have the old paper record for existing patients available for the medical provider as long as the provider feels necessary. At some point, the provider will no longer have a need for the paper record and it can be archived. 4) Some practices receive a lot of calls regarding patient questions or pharmacy requests. The summary page of the paper record can be scanned for all patients to establish an EHR that is useful in fulfilling these types of requests. One of the options for transitioning paper records can then be used to develop a more complete EHR for each patient 5) The conversion of paper records to electronic records is most readily accomplished by scanning. It can be done using practice personnel; however, it is more cost effective for an outside firm that will come onsite to do the work. Care must be exercised to follow all HIPAA regulations. A trained medical professional will still be required to ensure that the records are filed appropriately in the EHR system. 6) The file system used in establishing an EHR system must be carefully thought out to ensure that the medical provider can easily retrieve data. The EHR program being used is a good place to begin in planning the details of the file system while tailoring it to the specific type of medical practice. Documentation of the file system and the conversion procedure is a first step to maintaining consistent nomenclature and data format throughout the conversion

What are the professionalism guidelines for medical transcriptionists?

1) Display a professional manner and image: Working as a medical transcriptionist requires good hygiene practices and dress attire appropriate to the surroundings. The medical transcriptionist should always respect others and use good communication skills 2) Demonstrate initiative and responsibility: Demonstrating initiative means coming into work early enough to organize and begin the workday at the appointed time. All deadlines must be met or changes approved. 3) Work as a member of the health care team: The medical transcriptionist is a member of the health care team and as such must sign a business associate agreement and a confidentiality agreement. The medical transcriptionist should report incidents of confidentiality discrepancies and any perceived medical procedural errors to appropriate risk management personnel. 4) Prioritize and perform multiple tasks: The medical transcriptionist must prioritize the documents to be edited to satisfy turnaround time and maintain productivity standards. 5) Adapt to change: The medical transcriptionist must be flexible and willing to change. Technological advances require being open to new ways of handling medical documents. The medical transcriptionist's role and job description are changing to meet today's new demands 6) Enhance skills through continuing education: New technology, breakthroughs in medicine, and new medications are recognized daily as researchers explore ways in which to treat disease and increase longevity. The medical transcriptionist must remain current with new medical developments to maintain professionalism A qualified medical transcriptionist, described as someone who has a minimum of 2 years experience in performing medical transcription in a variety of medical and surgical specialties, may wish to become a certified medical transcriptionist (CMT), through a voluntary examination from the AHDI. Recent graduates, or medical transcriptionists with less than 2 years of experience, may apply to become registered medical transcriptionists (RMT). For additional information regarding AHDI credentialing, visit AHDI's website at www.ahdionline.org

What is the procedure for transcribing medical referral letters?

1) Gather all your necessary supplies or equipment and make sure that it is in good working order before beginning any procedure. For this particular procedure, you will need to have a computer and word processing software as well as source documents 2) After setting up the transcription equipment and inserting the tape, open the word processing software 3) Using the general formats for each document type, prepare and transcribe (type) the physician's dictation as shown on the source document. Use the proper punctuation and grammar. 4) When complete, save the document 5) Print the letter so the physician may sign it and turn in a copy to your instructor. Prepare a mailing envelope 6) Close the word processor when done

What are the HIPAA regulations regarding the use of medical documents?

1) Health Insurance Portability and Accountability Act (HIPAA) regulations are government rules and procedures that have resulted from legislation designed to protect the confidentiality of patient information ranging from medical records to personal identification numbers that, if divulged, could result in identity theft. 2) The medical transcriptionist can meet most HIPAA regulations by adhering to the following simple rules: 2a) Do not divulge medical records you transcribe to anyone other than the dictator, your supervisor, or an authorized QA person. Files should not be discussed with the patient. Do not divulge files to an attorney or insurance representative without consulting with risk management personnel. 2b) Safeguard files in your possession. Take reasonable steps to keep files secure, such as keeping tapes and hard copy of reports in a locked file cabinet, using passwords for computer files, installing virus protection software, and using a firewall if appropriate. Do not carelessly carry files around on your person or in your car 2c) Transmit files electronically only with the permission of your client or the dictating provider, and then agree on the proper procedures and protocols for transmission 2d) Have a signed business associate agreement or similar document that defines the protocols you are expected to follow to protect patient confidentiality These general rules do not constitute legal advice; consult with appropriate legal counsel for specific questions

What does the term "authentication" mean? What are all the ways in which medical reports can be authenticated?

1) In most cases, the provider dictating the information will sign or authenticate the document. At times an attending provider or physician assistant will be responsible for dictating the material. The provider's signature on the document indicates that the information was accurate and complete at the time of dictation and as transcribed 2) In today's technological world, electronic signatures have become common practice. The words electronically signed by [provider's name] underneath the signature are keyed to indicate an electronic signature. Electronic signatures may also be accomplished through: 2a) Use of alphanumeric computer key entries as identification 2b) Use of an electronic writing device 2c) Use of a biometric system Medicare and the Joint Commission guidelines require that the signature on medical reports, electronic or handwritten, be completed by the provider dictating the information and not delegated to anyone else. Federal law, state law, and Joint Commission accreditation standards all address the issue of electronic signatures.

Why is it so important for clinics to always have medical documents?

1) Medical reports become part of the patient's permanent medical record and are vital to continued patient care. Other providers, attorneys, insurance companies, or the court may review the medical reports in part or in their entirety. Therefore, the medical report must be neat, accurate, and complete. 2) Complete documentation of medical reports is also important for payment or reimbursement of services for which the provider expects to be paid. The billing and diagnosis codes reported on the health insurance claim form must be supported by the documentation contained within the medical report.

What is the changing role of medical transcription?

1) Medical transcriptionists (MT), sometimes referred to as health care documentation specialists, listen to voice recordings dictated by health care providers and create medical records in the proper format for the type of document and according to the standards of the facility. MT may also review and edit medical documents created by speech recognition technology, to ensure accuracy between what was dictated and the document produced. An MT that does not actually type the document, but rather compares dictation to the text produced by the voice recognition software, and then edits the text where needed, may sometimes be called a dictation editor or a medical transcription editor 2) Today's cost-conscious and rapidly changing economy along with new technology has brought about many changes to the MT profession.

What are the procedures that medical clinics must have in place to ensure patient confidentiality?

1) Protocols are the procedures your clinic has in place to ensure patient confidentiality. You are usually required to sign a confidentiality agreement stating that you will comply with the established procedures. Your contracts, together with the protocols, become a part of the institution's documentation demonstrating compliance with HIPAA regulations. The purpose of your signing a contract is to substantiate that you have received training and have been instructed in proper procedures to protect medical records. 2) From the medical transcriptionist's viewpoint, risk management involves protecting the confidentiality of the medical records and ensuring the accuracy of those records 3) Medical transcriptionists are in an excellent position to assist the risk management office, through their commitment to quality and their awareness of confidentiality procedures and possible medical errors indicated in the dictated data. Should a problem or error be detected that could be a risk management problem, the medical transcriptionist should immediately notify his or her superior, clinic manager, risk management officer, or the employer's or client's legal staff according to clinic policy 4) You will recall from chapter 7 that ethics are not laws but rather standards of conduct. These standards vary from state to state, so you should research your specific state's standards. The AHDI adopted a Code of Ethics (see the AHDI website for the AHDI Code of Ethics available at: www.ahdionline.org by searching for "Code of Ethics") for professional medical transcriptionists 5) Although, in certain cases, the medical transcriptionist can be held financially responsible for errors and omissions, the medical transcriptionist usually is under the jurisdiction of respondeat superior, meaning that the provider-director or clinic manager is responsible for the wrongful acts of the medical transcriptionist working under his or her supervision. This is not meant to imply that medical transcriptionists should not protect themselves by instituting some personal risk management, such as carrying errors and omissions insurance. Insurance should be considered particularly if the medical transcriptionist is operating a home business and contracting transcription work. 6) Medical records are documents governed by laws and may be subpoenaed for review by various courts. The medical report may play a major role in substantiating injury or malpractice claims

How can the transcribed medical report be formatted? What types of information are commonly included in transcribed medical reports?

1) The transcribed medical report may be formatted in a variety of styles similar to business correspondence. 2) The types of information that are commonly included in transcribed medical reports are: 2a) Chart notes and progress notes: Chart notes, sometimes referred to as progress notes, are a concise description of the patient's encounter with the medical clinic. They are chronologically listed and may include in-person visits to the clinic and telephone and electronic mail (email) inquiries. Chart notes should be filed in the chart within 24 hours of the encounter. The present problem, the provider's physical findings, and the treatment plan should be identified within the chart note. Laboratory test results also may be included. The provider or clinic personnel may enter chart note information as informal handwritten notes, or keyed notes affixed to the appropriate space. All notes documented must include the date, time, and signature of the person entering the data along with his or her credential. This information is pertinent for follow-up questions or for litigation purposes. 2b) History and physical examination reports: The history and physical examination (H&P) report documents information relating to the patient's main reason for treatment. The report is divided into two sections. The first is the history, which includes the chief complaint (CC) or present problem (PP), a description of symptoms, problems, or conditions that brought the patient to the clinic; history of the present illness (HPI), a chronological description of the development of the patient's illness; past medical and surgical history; family history; and social history. The second section is the review of systems (ROS) and inquiry about the system directly related to the problems identified in the HPI. The provider determines the extent of the examination performed and documented based on the problems presented. The findings of the actual physical examination make up the documentation for the physical examination section of the report. The Joint Commission accredits and regulates all policies and procedures of hospitals and provider's clinics owned by hospital organizations. The Joint Commission requires that hospitals provide H&P reports to be filed in patient charts within 24 hours of admission. Occasionally, the patient is seen in the provider's clinic and a decision is made to admit the patient to the hospital. In this case, the examination is performed in the clinic, but the report is dictated to the hospital that transcribes the document and files it within the patient's chart. The H&P format may also be used to document a patient's annual physical examination in the clinic. 2c) Radiology reports: A radiology report is a description of the findings and interpretations of the radiologist who studies the diagnostic procedure. Examples of radiology reports are x-ray studies, computed tomography (CT) scans, magnetic resonance image (MRI) scans, nuclear medicine procedures, and fluoroscopic studies. In some cases, a contrast medium is administered either orally or by injection before the procedure is performed. A scan is a procedure that requires the use of radioactive isotopes. When dictating, the radiologist may switch from present to past tense; that is, the procedure was performed in the past tense, and the findings are given in the present tense. Stereoscopy and tomography are technologies that view structures within the body in dimensions or layers. Computed tomography uses radiography with computers to visualize a slice of the body part. Sonograms and echograms are another imaging technology that uses high-frequency sound waves to compose a picture of an area of the body. Magnetic resonance imaging produces sectional images of the body without the use of radiology. New technologies create the need for understanding the imaging process and appropriate documentation of patient information. When transcribing radiology or imaging reports, the date of service should be used rather than the date of the dictation. Other details to be included within the report may include: -Number and type of views taken -Any special circumstances that could affect the examination -Quality of the study (clear or blurry) -Abnormal findings -Normal findings -Radiologist's impression, interpretation, diagnosis, and recommendations -Signature of the radiologist The report should be files in the patient's chart within 4 to 8 hours of the procedure. Sufficient documentation must be in the report for the provider to use if he or she must prove that the study was medically necessary or if justification for reimbursement is required 2d) Operative reports: The operative report (OR) chronicles the details of a surgical procedure performed in a hospital, outpatient surgical center, or clinic. The surgeon or assistant dictates the OR immediately after the operation. The OR describes the surgical procedure, preoperative and postoperative diagnoses, and specimens removed. It sometimes include a sponge count and instrument inventory, an estimate of blood loss, and the condition of the patient on leaving the operating room. The report should also include the name of the primary surgeon and any assistants. The type of anesthesia and name of the anesthesiologist should also be included in the report. Often the report will end with disposition or where the patient was transferred when he or she left the operating room and the condition of the patient at the time of transfer. The authenticated report should be filed in the chart as soon as possible after surgery so that the other staff members caring for the patient will have needed information. 2e) Pathology reports: A pathology report is generated to describe the gross and microscopic examinations performed on organs, lesions, tissue samples, or body fluid removed during the surgical procedure. In some cases, the pathologist examines the specimen before the patient is sutured to determine if a more extensive surgical procedure is required (i.e., in the case of malignant tumors). Pathologists generally dictate the report in the present tense because they interpret the pathologic findings as they view specimens. The report must be completed within 24 hours of receipt with a copy maintained by the laboratory and copies sent to each provider involved in the case. The original is maintained in the patient's chart. 2f) Consultations: When one provider requests the services of another provider in the care and treatment of a patient, a consultation report is generated. The information may be disseminated in the form of a report or within the body of the letter. The contents of the consultation report/letter usually consist of all of the elements of an H&P with a focused history of the patient's illness and the body system directly related to the consultant's area of specialty. The consultant also includes within the report letter the findings, supporting laboratory data, diagnosis, and suggested course of treatment. The report/letter usually ends with a comment from the consulting provider thanking the admitting provider for the referral. It should be filed in the patient's medical record within 24 hours of receipt. 2g) Discharge summaries: The discharge summary (DS) documents the patient's history of hospital admissions. The DS includes the reason for hospital admission, a description of what transpired while the patient was in the hospital, the final diagnosis, follow-up instructions, discharge medications, patient's condition at discharge, and prognosis for recovery. If the patient is transferred to another facility such as a skilled nursing facility, the report is changed from DS to transfer summary. If the patient has expired during the stay, the report is usually called a death summary. The Joint Commission requires that the completed DS be filed in the patient's chart within 48 to 72 hours of discharged from the hospital 2h) Autopsy reports: An autopsy report may also be called an autopsy protocol, a necropsy report, or a medical examiner report. Autopsies are performed to determine the cause of death or to ascertain and confirm presence of disease. It is important to understand that state law requires that autopsies be performed in certain situations. For example, an autopsy report is required when someone dies suddenly, when someone dies while unattended or in the case of suspicion of crime. When transcribing an autopsy report, more words should be spelled out and abbreviation use kept to a minimum because these records may be entered into a court of law and must be accurate and clearly understood. Many states require that military time be used when documenting the time a body arrives at the coroner's office. Temporary anatomic diagnoses should be placed in the medical report within 72 hours and in the completed report within 60 days 2i) Correspondence: It is important for the medical transcriptionist to remember that all forms of medical correspondence also are considered medical documents and must be transcribed with the same care as any other medical report would.

What are the reasons for justifying outsourcing medical transcription?

1) Transcription is a task that is presently outsourced by many large clinics and hospitals. Outsourcing is the practice of contracting with a service outside the clinic or hospital to a company where the task can be accomplished at a lower cost and with a faster turnaround time. Outsourcing companies usually are located in countries where a source of English-speaking educated labor is present, the pay rate is low, and a stable business climate exists. Currently, outsourcing organizations are located in areas of the United States and Canada as well as offshore at companies primarily located in the United Kingdom, India, and the Philippines. 2) Today's medical clinics must keep a keen eye on the bottom line--cost. Some advantages given to support outsourcing of medical transcription include the following: 2a) Outsourcing transcription frees administrative and support personnel to complete tasks that often are delayed because of time crunch factors 2b) Outsourcing companies are on the job 24/7 and 365 days of the year, so the medical clinic need not be concerned about vacation periods or sick leave. Someone is always on the job. 2c) Outsourcing companies focus on transcription without having to answer telephones, schedule appointments, or deal with any number of interruptions encountered in the medical clinic. Therefore, documents are more accurate, standardized, and completed with less turnaround time. 2d) Outsourcing transcription frees floor space (real estate) previously used to support a line item expense and converts it to a source of revenue 2e) Outsourcing saves on costly employee benefits packages 3) Digital dictation by the provider can be readily sent to the outsource organization that performs the transcription using the internet, with the completed document returned in similar fashion. Some important considerations before outsourcing medical transcription include the following: 3a) Be sure the medical clinic and the transcription service are using compatible hardware and software 3b) Investigate quality assurance, security, HIPAA, and confidentiality measures 3c) Be cost conscious. Most transcription fees are calculated by the line, but it may be more cost effective to pay by the minute of recorded dictation time. A digital dictation system allows one to measure to the 10th or 100th of a minute. 3d) A transcription service that uses a digital dictation system should have a user-friendly method of tracking transcribed documents. The work should be able to be located in less than 3 minutes 3e) When using a digital dictation system, a provider's dictation is available to the transcriptionist as soon as the provider hangs up the phone, allowing for no lost time, which equates to cost containment 4) Outsourcing is rapidly eliminating the need for the traditional transcriptionist in medical facilities. This practice is in turn being replaced by the use of voice recognition software.

What is the impact of voice recognition software on medical transcription?

1) Voice recognition software (VRS), also known as speech recognition, automatic speech recognition (ASR), or natural language recognition software, converts voice to text using a computer. In essence, the software "translates" the sounds spoken into written words. This type of program has improved greatly in recent years, translating with little error. Specialized programs are capable of translating highly technical medical terminology. 2) The latest generation of VRS uses continuous speech technology, which allows the speaker to speak more naturally. All VRS systems require an enrollment process, during which a person sits at the computer and reads sample text out loud to help train the speech recognition software to understand the particular voice pattern. VRS integrates easily with Windows applications, including Microsoft Word, Outlook Express, Internet Explorer, and AOL Instant Messenger. Some VRS products are marketed that work with personal digital assistants (PDAs) and smartphones

What are the responsibilities of the medical transcriptionist serving as editor of medical documents?

1) With the use of EHR, outsourcing, or VRS methods of transcription, the MT professional is now serving as the quality assurance (QA) manager, responsible for risk management, and the editor or auditor of transcribeddocuments. A QA manager establishes a process that provides accurate, complete, consistent health care documentation in a timely manner. 2) Editing is the process of reviewing the transcribed document for accuracy and clarity. It is important to remember that one must not change the dictator's style or meaning when editing. Common errors are usually in sentence structure, punctuation, and spelling. They are easily changed without altering the dictator's style or meaning. Sound-alike words are another area where errors occur. 3) The Association for Healthcare Documentation Integrity (AHDI) recommends the following principles when reviewing a document: 3a) Compare the transcribed report against dictation. Do not just read the document. 3b) Use industry-specific standards for style, punctuation, and grammar (i.e., "The Book of Style for Medical Transcription"). 3c) Consider risk management issues 3d) Third parties, such as the QA person, proofing a document should provide feedback to the transcriptionist. Although 100% accuracy is desired, accuracy of audited documents should not be less than 98%. Accuracy less than this figure requires corrective action 4) If the MT encounters a term that cannot be interpreted or something new that cannot be referenced, the MT should flag that section of the document to alert the dictator that something needs to be corrected or resolved. The flagged message may indicate the provider is cut off, what the term sounds like, or the message is incomprehensible. Provide as much information as you can to assist the dictator in recalling the dictated area in question 5) Flagging procedures vary from one facility to another and may depend upon the method use to transcribe documents. In large facilities using EHR, VRS, or outsourcing, the flagged documents may be referred directly to QA personnel. The notation may be incorporated into the computerized document using a color-code approach with a flag message. The correct information then can be added to the document and the color coding removed. In-house flagging may simply consist of a sticky note or a preprinted flag attachment

What does the term "neat" mean?

A medical report that is legible and assembled to permit easy access to information as needed

What are the confidentiality and legal issues that are associated with the use of medical documents?

Confidentiality means treating the patient's medical information as private and not for publication. The patient has a right to privacy; therefore, medical information is privileged. Privileged information may only be communicated with the patient's permission or by court order. The medical transcriptionist must learn to follow the motto: What you see here and what you hear here must stay here when you leave here.

What is the format that hospitals and other practices may use for transcribing medical reports?

Hospitals and other practices may require a specific format for reports different from those described in the following examples. A few helpful formatting rules are: 1) Use section headings that clarify the report 2) Do not add sections left out by the dictator 3) Do not include unnecessary confidential information unless specifically instructed to do so 4) Note who dictated the report, if not the attending provider, and provide space for both to sign. The initials of the transcriptionist should be on the signature page 5) Use 1-inch margins all around, unless the document is to be filed in a chart that has a top opening, then use 1.25-inch margin at the top only. If using sticky paper for chart notes, use 0.5-inch margins 6) Use paragraph format

What does the term "complete" mean?

Indicates that the document has been dated correctly and signed or initialed by the dictator

What are the qualities and skills that people need to have in order to be successful in their career as a medical transcriptionist?

People who wish to be successful in their career as a medical transcriptionist need to have the following qualities and skills: 1) Enjoy detective work and be curious 2) Be resourceful and willing to learn new things 3) Be self-disciplined 4) Be detail-oriented 5) Be independent 6) Be a perfectionist 7) Have integrity 8) Have an understanding of the importance and legal implications of medical confidentiality

What are the guidelines of turnaround time and productivity?

Specific time limits are often established for completion of medical reports. Turnaround time (TAT) indicates the specific time period in which a document is expected to be completed from the time it is received by the transcriptionist until it is returned to the provider to sign and made a part of the permanent medical record. Turnaround times for hospital reports fall into three categories: 1) STAT reports: These should be completed within 2 to 4 hours 2) Current reports: These should be completed within 24 hours or less 3) Old reports or aged reports: Discharge summary (DS) reports are an example, except when the patient is being transferred to another facility. Old reports should be completed within 48 to 72 hours or less 4) When requesting copies of a medical record, the usual turnaround time (TAT) is 7 to 10 business days Different facilities have different requirements; however, the transcriptionist or clinic personnel responsible for medical records should be aware that failure to meet deadlines could result in disciplinary or legal action. The reason for this stringent adherence to turnaround time is that STAT and current reports can influence timely treatment of the patient Workload, as well as productivity of the transcriptionist, affects turnaround time. When workload is too great to meet turnaround times, the medical records administrator must be notified immediately. Once a job has been accepted, the transcriptionist or transcription service is legally bound to meet the schedule short of a major catastrophe of the legally considered to be an "act of nature"

What does the term "accurate" mean?

The dictation has been transcribed as dictated

What is the job outlook for medical transcriptionists?

The medical transcription career has changed significantly in the United States. The career continues to evolve with the introduction of new technology and outsourcing. Most healthcare providers use either digital or analog dictating equipment to transmit dictation to medical transcriptionists. The internet has grown to be a popular mode for transmitting documentation and allows for faster turnaround time. Speech recognition technology electronically translates sound into text and creates drafts of reports. The medical transcriptionist serves as a quality assurance (QA) manager, oversee risk management, and function as editors or auditors of medical documents. Medical transcriptionists are invisible, yet invaluable members of the patient care team