Transcription Services Canada Advantages of Dictating/Transcribing Medical Notes vs. Handwriting Medical Notes

Productivity

Studies have shown that physician productivity increases when progress notes and other medical reports are dictated rather than hand-written. According to industry sources, when comparing writing medical reports versus dictating, an average person can dictate 85-95 words per minute compared to 20 words per minute for writing. For example, a document of 200 words takes about 10 minutes to write versus 2.22 minutes to dictate. Based on this time saving and five patients per hour, this equates to saving the dictating physician up to three and half (3 ½) hours’ time per eight-hour shift.

Also, during the course of the day, a physician is likely to find one to five minutes of uninterrupted time to dictate, rather than nine to twenty-two minutes of writing time. Besides the actual time involved in writing the report, it is impossible to factor into the equation the inevitable interruptions encountered and delays associated with losing one’s train of thought.  Studies have shown that each interruption, regardless of how long it’s for, can take you up to seven minutes to get back to your train of thought from before the interruption.

Document Accuracy

The accuracy of medical reports improves greatly when dictated immediately after the patient exam rather than at the end of the day when it becomes more likely for some crucial information to be left out. Thoughts flow faster while speaking and “dictating” the facts of a patient visit, when compared to writing them down.

Legibility

The inability to read physicians’ handwriting is an age-old problem and is an ongoing documentation concern. This may delay critical patient care decisions, affect reimbursement, have a negative impact on medical-legal issues and delays can increases risk management related issues.

Improved and Increased Reimbursement

In the era of needing to be aware of, and sometimes accountable for, cost containment, documentation can play a key factor. With provincial healthcare plans, payment is directly associated with the thoroughness and the level of detail included in documenting the patient visit. Most codes are based on detailed documentation that includes the scope of patient history obtained, the extent of the examination performed and the complexity involved in making medical decision. Sufficient details must be included while documenting each patient visit to obtain maximum levels of reimbursement. A poorly documented handwritten report, with incomplete or insufficient details of patient’s visit, when audited, may result in a lower level of reimbursement, or no reimbursement at all.

Medical Transcription increases healthcare provider’s productivity and document accuracy.  It can also lead to better financial reimbursement from provincial healthcare agencies and insurance companies. It also helps in reducing of medical-legal issues and increases positive risk management.

Adapted from an article by Witt, D. Transcription services in the ED, The American Journal of Emergency Medicine, Volume 13, Issue 1, Pages 34-36 http://linkinghub.elsevier.com/retrieve/pii/0735675795902376

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