Verbatim transcription and its use in EHR

As we know that medical transcription helps in documenting the conversation happened between a doctor and his patient. Since this transcription is based upon the video or audio files that represents the conversation to a transcriptionist, sometimes it becomes difficult to understand the words spelled by the doctor or the patient. Thus, while transcribing, an error may happen which induce discrepancies in the documentation process as well as in the entire healthcare management system. Suppose one diabetic patient is recommended by his doctor to have 8 units of insulin in a day. But due to transcriptional error, the patient is receiving 80 units of insulin instead of those 8 units of insulin. This really creates turbulence in the health care management system as the overdosage of the medicines creates health issues like brain damage, cardiac arrest and so on which are even life-threatening.

There are total three types of medical transcription process. Among them, verbatim transcription is one of the most time consuming and expensive process. You might think that medical transcriptionists are now using the voice recording files that get transcribed in the form of text but then how such error can take place right? This happens because of using the template structure that allows editing transcription, the other type among the three different types of transcription. 

Electronic Health Record system or EHR is basically the digital chart of a patient's details. This includes the different information about a patient like admission date and time, case history, previous treatment, ongoing treatment, the name of medicines recommended to the patient, medical tests etc. Now, this chart only represents the minute details that were told to the patient. Now while transcribing this data from a video file or an audio file can have misinterpretation. Or the written data might get misinterpreted by the patient party. This is dangerous. So, it is required to eliminate such issues that help in producing error-free details of a patient. Now, this verbatim transcription process helps a lot in this regard.

Do you want to know how this helps? Verbatim transcription allows to record the minute details of the conversation and the text format is represented exactly in the way it is told to the patient. Let me give you one example:

Lady: Our neighbor really helped us a lot. We received good support while taking my baby here. (Baby starts crying)

Doctor: How did your baby fell down? (Nurse is telling, sir everything is ready, you can start stitching).

Lady: Please take care of my baby (talking to her baby in between for 35seconds…….ummhh don't cry, my dear).

See this entire conversation includes the background sounds, other speech and most importantly the words are transcribed exactly in the way it was told to the doctor or to the patient’s mother. Recording of data and transcribing it in the same form helps in eliminating the errors caused by misinterpretation. That is what a verbatim transcription means. It represents not only the conversation between your doctor and your patient but also reflects their way of talking, perspectives, circumstances, and background sounds, etc. Don't you think that this is really awesome where you are not only getting your patient's minute details through the EHR system but also able to understand what exactly happened or told by the doctor.