Medical

Transcription
 Objectives
► 1. Define medical transcription.
► 2. List four necessary skills of the
entry-level medical
transcriptionist.
► 3. Describe the functions of the AAMT.
► 4. Express the importance of HIPAA in
medical transcription.
 Medical Transcription
► Medical transcription, also known as
MT, is an allied health profession,
which deals in the process of
transcription, or converting voice-
recorded reports as dictated by
physicians and/or other healthcare
professionals, into text format.
 Medical Transcriptionist
► An individual who performs medical
transcription is known as a medical
transcriptionist or an MT.
► A medical transcriptionist is the person
responsible for converting the patient's
medical records into text from recorded
dictation.
Curricular requirements, skills
and abilities
► Knowledge of medical terminology.
► Above-average spelling, grammar,
communication and memory skills.
► Ability to sort, check, count, and verify
numbers with accuracy.
► Skill in the use and operation of basic
office equipment/computer;
eye/hand/foot coordination.
► Abilityto follow verbal and written
instructions.
► Records maintenance skills or ability.
► Above-average to excellent typing skills.
Basic MT knowledge, skills and
abilities
► Knowledge of basic to advanced medical
terminology is essential.
► Knowledge of anatomy and physiology.
► Knowledge of disease processes.
► Knowledge of medical style and grammar.
► Average verbal communication skills.
► Above-average memory skills.
► Ability to sort, check, count, and verify
numbers with accuracy.
► Demonstrated skill in the use and operation
of basic office equipment/computer.
► Ability to follow verbal and written
instructions.
► Records maintenance skills or ability.
► Above-average typing skills.
► Knowledge and experience transcribing (from
training or real report work) in the Basic Four
work types: History and Physical Exam,
Consultation, Operative Report, and
Discharge Summary.
► Knowledge of and proper application of
grammar.
► Knowledge of and use of correct
punctuation and capitalization rules.
► Demonstrated MT proficiencies in
multiple report types and multiple
specialties.
 Duties and responsibilities
of a medical transcriptionist
► Accurately transcribes the patient-identifying
information such as name and Medical
Record or Social Security Number.
► Transcribes accurately, utilizing correct
punctuation, grammar and spelling, and edits
for inconsistencies.
► Maintains/consults references for medical
procedures and terminology.
► Keeps a transcription log.
► In some countries, MTs may sort, copy,
prepare, assemble, and file records and
charts (though in the United States (US) the
filing of charts and records are most often
assigned to Medical Records Techs in
Hospitals or Secretaries in Doctor offices).
► Follows up on physicians' missing and/or late
dictation, returns printed or electronic report
in a timely fashion (in US Hospital, MT
Supervisor performs).
► Performs quality assurance check.
► May maintain disk and disk backup system
(in US Hospital, MT Supervisor performs).
► May order supplies and report
equipment operational problems (In US,
this task is most often done by Unit
Secretaries, Office Secretaries, or Tech
Support personnel).
► May collect, tabulate, and generate
reports on statistical data, as
appropriate (in US, generally performed
by MT Supervisor).
The medical transcription
process
Transcriptionists are never, ever
permitted to guess, or 'just put in
anything' in a report transcription.
 AAMT Code of Ethics
Preamble
This Code of Ethics of the American
Association for Medical Transcription
(AAMT) sets forth standards of conduct
and ethical principles for the medical
transcriptionist professional that all
members of AAMT and individuals
holding the CMT designation are
expected to follow.
► Medical transcriptionists are vigilant
advocates for quality patient documentation
and adhere to the highest privacy and
security provisions. We uphold moral and
legal rights of patients, safeguard patient
privacy, and collaborate with care providers
to ensure patient safety, public health, and
quality of care to the fullest extent possible,
through the practice of medical transcription.
► AAMT is responsible for expressing the values
and ethics of the profession and for
encouraging its members to function in
accordance with these values and ethics,
especially all individuals who hold the
certified medical transcriptionist credential.
AAMT members are aware that it is by our
standards of conduct and professionalism
that the entire profession of medical
transcription is evaluated.
► We conduct ourselves in the practice of
our profession to bring dignity and
honor to ourselves and to the profession
of medical transcription as medical
language specialists.
 Medical Transcriptionist
professionals:
► Maintain confidentiality of all patient
information including but not limited to
peer reviews, quality improvement, and risk
management protocols with special effort to
maintain data security in electronic
communications.
► Implement and maintain standards of
professional transcription practice.
► Respect the rights and dignity of all
individuals.
► Continue professional growth enhancing
knowledge and skills, including continuing
education, networking with colleagues,
professional reading, and certification.
► Strive to provide accurate and timely
information.
► Exercise integrity in professional practices
including work or professional experience,
credentials, affiliations, productivity
reporting, billing charges, and payment
practices.
► Comply with all laws, regulations, and
standards governing the practice of patient
documentation.
► Foster environments of employment that
facilitate integrity, professionalism, and
protection of patient information.
► Strive to advance the goals and purposes of
the Association and work for the
advancement and good of the profession.
 Health Insurance Portability
and Accountability Act

► The Health Insurance Portability and

Accountability Act (HIPAA) of 1996
(P.L.104-191) [HIPAA] was enacted by
the U.S. Congress in 1996. It was
originally sponsored by Sen. Edward
Kennedy (D-Mass.) and Sen. Nancy
Kassebaum (R-Kan.).
 Title I: Health Care Access,
Portability, and Renewability

► Title
I of HIPAA regulates the
availability and breadth of group health
plans and certain individual health
insurance policies.
Title II: Preventing Health Care
Fraud and Abuse;
Administrative Simplification;
Medical Liability Reform
► TitleII of HIPAA defines numerous
offenses relating to health care and sets
civil and criminal penalties for them. It
also creates several programs to control
fraud and abuse within the health care
system.
 Privacy Rule

► The HIPAA Privacy Rule regulates the use

and disclosure of certain information held by
"covered entities" (generally, health care
clearinghouses, employer sponsored health
plans, health insurers, and medical service
providers that engage in certain
transactions.) It establishes regulations for
the use and disclosure of Protected Health
Information (PHI).
Protected Health Information
► PHI is any information held by a
covered entity which concerns health
status, provision of health care, or
payment for health care that can be
linked to an individual. This is
interpreted rather broadly and includes
any part of an individual's medical
record or payment history.
 Security Rule

► The Security Rule complements the

Privacy Rule. While the Privacy Rule
pertains to all Protected Health
Information (PHI) including paper and
electronic, the Security Rule deals
specifically with Electronic Protected
Health Information (EPHI).
Three types of security safeguards
 Administrative Safeguards – policies and
procedures designed to clearly show how the
entity will comply with the act
 Physical Safeguards – controlling physical
access to protect against inappropriate access
to protected data
 Technical Safeguards – controlling access
to computer systems and enabling covered
entities to protect communications containing
PHI transmitted electronically over open
networks from being intercepted by anyone
other than the intended recipient.
 Protected health information
► Protected health information (PHI),
under the US Health Insurance
Portability and Accountability Act
(HIPAA), is any information about
health status, provision of health care,
or payment for health care that can be
linked to a specific individual. This is
interpreted rather broadly and includes
any part of a patient’s medical record or
payment history.
PHI that is linked based on the
following list of 18 identifiers
must be treated with special care
according to HIPAA:
1. Names
2. All geographical subdivisions smaller
than a State, including street address,
city, county, precinct, zip code, and
their equivalent geocodes
3. Dates (other than year) for dates
directly related to an individual,
including birth date, admission date,
discharge date, date of death; and all
ages over 89 and all elements of dates
(including year) indicative of such age,
except that such ages and elements
may be aggregated into a single
category of age 90 or older
4. Phone numbers
5. Fax numbers
6. Electronic mail addresses
7. Social Security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers and serial
numbers, including license plate
numbers;
13. Device identifiers and serial numbers;
14. Web Uniform Resource Locators (URLs)
15. Internet Protocol (IP) address numbers
16. Biometric identifiers, including finger,
retinal and voice prints
17. Full face photographic images and any
comparable images
18. Any other unique identifying number,
characteristic, or code (note this does not
mean the unique code assigned by the
investigator to code the data)
 OFFSITE
CHECKLIST:
! Confidentiality Agreement
► All MTs, whether IC or employee, should be required
to sign a confidentiality agreement stating that
disclosure of confidential information to anyone other
than the client or MTSO is prohibited. Disclosure of
confidential information is prohibited indefinitely,
even after termination of the contract or business
agreement. Confidentiality requirements do not end
when the business relationship ends. All MTs should
be expected to uphold the Code of Ethics adopted by
the American Association for Medical Transcription
with regard to PHI.
! Documentation of Training
► All
MTs, whether IC or employee,
should have documentation of having
received appropriate training, either in
HIPAA and state regulations involving
security and privacy of PHI or in the
institution or transcription company's
policies and procedures regarding
safeguarding PHI.
 ! Work Performed in a Secure
Area
► The offsite MT should provide
documentation to certify that work will
be performed in a secure area, in either
an office with a door that can be locked
or an area that is accessed only by the
MT with the computer facing away from
view by passers by, and that
appropriate safeguards are taken to
prevent anyone overhearing the voice
files while processing reports.
! Destruction of Hard Copy PHI
► Shredders should be used for printed
material containing PHI such as patient
appointment or hospital census sheets.
If faxes are received on a machine that
uses roll-style film cartridges to print,
these need to be destroyed as they
preserve a complete copy of any faxed
material.
 ! Other Media.
►• Physical Media: Information sent via
audiocassette or other media (disks)
that needs to be shipped or mailed
should have a designated recipient who
must sign upon receipt and should only
be sent by a carrier who can track the
shipment. When not in use, such media
should be stored in a locked, fireproof
receptacle/storage cabinet.
►• Faxing: If faxes are sent by the MT,
transmittal confirmation sheets should
be saved for future verification. The MT
should always use a fax cover sheet.
Preprogrammed fax numbers should be
used whenever possible. and when not
preprogrammed the number dialed
should be verified before hitting "send".
►• E-Mail: Encryption of e-mail and
attachments containing PHI is
recommended. The Security Rule
designates this as an "addressable"
issue, meaning that it is up to the
Covered Entity to decide whether to
encrypt and to what level.
 ! Access to Voice Files and
Demographic Databases
► Passwords should be required for
access. The offsite MT is responsible for
maintaining confidentiality by never
sharing passwords or access and
always logging out of databases or
transcription platform when finished.
Each person is accountable for all
activity under his/her password and
account.
 ! Offsite Computer Security
► If transcription is done on a company-
or institution-owned computer, the
owner of the computer should be
responsible for securing it (see above).
If transcription is done on an MT-owned
computer:
► A. The MT must provide the employer or client with a
signed statement assuring that the computer used to
process PHI is a work tool and is not shared by other
family members. If this is not possible for some
reason, the MT must provide assurance that
acceptable measures have been taken to ensure
patient confidentiality, such as password protected
folders and encrypted files. Passwords must be kept
secure and should be changed frequently (also see
Disaster Recovery section below). A password-
protected screen saver and the habit of locking the
computer whenever one steps away from it is also
recommended.
► B. The MT should have a basic working
knowledge of the hardware/software
programs used.
► C. Computers with internet access should
have active firewalls in place to prevent
others from gaining access to the computer
without the MT's knowledge.
► D. Anti-virus programs, operating systems
(i.e. Windows updates) and spyware detection
software should be kept up to date with
periodic upgrades as recommended by the
manufacturer.
► E.Many kinds of software contain
"automatic update" capabilities that
enable them to update themselves by
connecting to an internet site to
download and install new things
automatically, potentially allowing
unauthorized access to files kept in the
computers. The update capability
should be turned off and should be
performed manually when necessary.
► F. Software programs such as games and music
programs that allow file sharing should not be
installed on any computer where PHI is used.
► G. Work should be returned immediately upon
completion and no copy should be stored on the hard
drive. When PHI is retained until the client/service
acknowledges receipt and payment is received, then
it should be removed from the computer, transferred
to disk/CD and stored securely in a fireproof, locked
cabinet or receptacle. Once receipt is acknowledged
and payment received, the media should then be
appropriately destroyed. Work logs should be
handled in the same manner.
► H.If computer equipment must be
repaired, all PHI should be removed
from the computer hard drive. If a hard
drive is replaced, the MT should ensure
that the old hard drive is destroyed. A
record should be kept of who made the
repairs.
 ! Disaster Recovery / Backup
Planning
► Precautions
should be taken for
equipment failure and adverse
environmental conditions such as
power outages.
► A. Set software applications that have auto backup
features to a frequency of 2 to 5 minutes.
► B. Use surge protectors for computers and other
devices such as transcribers, including both
electrical connections and phone line connections.
► C. Consider a UPS backup power supply for
computers so that MTs will have a few minutes to
save documents in the event of a power outage.
► D. Back up text files to a removable backup device
(floppy, CD, etc.) on a daily basis in case work needs
to be re-sent and the computer is down.
► E. Routinely back up any voice files that have
not been transcribed to a second computer or
removable media in case of computer failure.
► F. If a digital dictation system is used,
consider developing an alternate method of
dictation (i.e. hand-held recorders) for use if
the system is down.
► G. Develop an alternate method for returning
work if the normal manner is not available,
such as if internet access is unavailable.
► H. The offsite MT's employer or MTSO should always
have updated computer passwords in case the MT is
incapacitated. The MT should also provide an
emergency contact person who can physically access
the MT's work area and computer. In an emergency
the employer or MTSO can give the emergency
contact the passwords and have any PHI retained by
the MT retrieved or destroyed. If tapes are used, the
emergency contact person should be aware of where
untyped tapes are kept so that these can be returned
to the employer or MTSO immediately. In the event of
the MT's death or permanent disability, sending the
computer to the employer or MTSO for removal of
PHI is recommended.
 ! Contract Termination
► Upon termination the MT will provide
certification that all PHI and
demographic information has been
appropriately returned and/or
destroyed.
 ! Security / Privacy Breach
► Inthe case of unauthorized disclosure
or theft of PHI or hardware, the
employer, medical transcription
company or client must be notified
immediately. Steps must be taken to
ensure that further breaches will not
occur and these steps must be
documented.