Medical Transcriptionists Make for Legible Medical Records

Caller:  Can you transcribe handwritten patient records?

2Ascribe:  Maybe. Can you read them?

Caller:  Not really.

2Ascribe:  If you can’t read them, why do you think we can?

Caller:  Don’t you type up doctor’s handwritten notes all the time?  Aren’t you used to reading their handwriting?

2Ascribe:  Sorry, no, our physicians dictate their letters and notes. Why don’t you ask the doctor to dictate what he wrote? Then we can transcribe the audio.

Caller:  OK, I’ll get back to you.  Thanks.

2Ascribe:  Bye.

Caller:  Hi, I was just talking to you a few minutes ago.

2Ascribe:  Right. So how did it go with suggesting the doctor dictate what he wrote?

Caller:  He says he can’t read them either.

This is an actual phone call and, as a medical transcription service, we’ve received many like this over the years. Illegible patient records are a real concern, especially when they are needed for continuing patient care and for court cases. 2Ascribe’s medical transcriptionists are able to transcribe many different audio to text formats, including Independent Medical Exams and Independent Paper Reviews.

We started to keep track of how often there was an issue with illegible medical records. Here’s a small sampling of what our medical transcriptionist’s have reported:

I reviewed the medical notes and records of Dr. L. from January 7, 20xx to

January 9, 20xx.  I should note at the outset that the notes of February 23, 2006 to 2010 are handwritten and illegible.

I have reviewed the clinical notes and records of Dr. C…  I find these records to be handwritten and mostly illegible.

I have reviewed the clinical notes and records of Dr. T.  These notes are handwritten and unfortunately, totally illegible.

According to the clinical notes and records of Dr. W., the notes are handwritten and should be transcribed.

There are handwritten progress notes. It is not clear who is the clinician who wrote these progress notes; however, these should be transcribed.

I have been provided with clinical notes and records of Dr. S.  However, these are illegible and should be transcribed.

The file does contain random unsigned handwritten progress notes, which are illegible.

There are various handwritten notes on file that are illegible…

While our medical transcriptionists may not get every single word that’s dictated, we try our very best.  And you have the reassurance that it’s not you being mentioned by name in a medical-legal report, and it’s not your handwritten notes that are illegible.

2Ascribe Inc. is a medical transcription services agency located in Toronto, Ontario Canada, providing medical transcription services to physicians, clinics and other healthcare providers across Canada and the US. Having recently introduced WEBscribe, a client interface portal for document management, 2Ascribe continues to implement and develop technology to assist and improve the transcription process for physicians and other healthcare providers. As a service to our clients and the healthcare industry, 2Ascribe offers articles of interest to physicians and other healthcare professionals, medical transcriptionists and office staff, as well as of general interest. Additional articles may be found at https://www.2ascribe.com.

This entry was posted on in Dictation Tips, Transcription.

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