There are several reasons for medical transcription errors in reports.
- Transcription Oriented: poor quality transcription resulting from poor quality typing, an improperly trained transcriptionist or reports not being edited by a second qualified transcriptionist
- Dictator Oriented: poor quality recording, including a heavily accented voice, background disturbances, using a speaker phone, brushing the receiver up against the face and talking too quietly
Medical transcription errors
Classification of Error
Type of Error
a. patient ID incorrect
b. omission in dictation or a missing part
c. incorrect drug name or dosage
d. misuse of medical word so that it severely compromises the safety of the patient information.
Unacceptable, report must be sent back to be transcribed correctly
a. incorrect verb usage
b. spelling mistakes
c. failure to flag conflicting information (e.g. left/right, date or gender changes)
Notify transcriptionist of errors and request report be redone with corrections
a. grammar or format mistakes or any other errors
b. mistakes which have very little impact on the safety or the integrity of the medical report
Depending on how many errors there are, ask for report to be retyped.
In every case, provide feedback to the transcriptionist. And ask the transcriptionist for feedback as well. If there are a number of blank (*___) or unknown in the report, ask them what the problem was. For future dictations, you can improve the quality of your reports by improving the quality of the dictation. You may find out that the problem is poor quality sound recording (reduce background noise, use the telephone handset, not the speaker phone), a proper name that they couldn’t make out (spell out proper names whenever possible) or you spoke too quickly (slow down).
How to Provide Feedback to Improve Quality
When you are unhappy with the quality of a report, provide the transcriptionist or transcription company with the following:
- Report name (patient initials or Job #) and date dictated
- What was the problem with the report – see types of errors in above chart.
- Give specifics. For example, for formatting, don’t say it’s inconsistent; tell the transcriptionist what you want. For example, you want your headings bolded and underlined, but without a colon at the end. Or just that the font size varies; say you want it all to be 11 point Arial.
- What you would like them to do. If you’ve already edited the report and signed off on it, let them know. If you need it retyped, let them know when you need it by.
You can do this by printing the report and circling the mistakes and faxing it back to the company, or highlighting the errors and emailing it to them.
Types of Typing Errors
These can happen either when the report is dictated, or when the document is transcribed.
- Transposing two numbers e.g. 117 to 171
- Transposing letters e.g. dent vs. tend
- Transposing words e.g.
- Homophones – words that sound alike but have different meanings
- e.g. to/two/too, write/right, their/there/they’re
- Lack of consistency or common usage
- e.g. disk vs. disc – correct terminology today is ‘disc’ for all things anatomical as it comes from the Latin word ‘discus’, and is the accepted terminology by Federative International Committee on Anatomical Terminology,
Reducing Medical Transcription Errors
- Transcriptionists need to keep word lists for drug names (generic and Trade Names), specialty related vocabulary and tests.
- Create Style Guides for clients with their specific feedback including particular phrases a physician may dictate, drugs that they regularly prescribe and vocabulary particular to their specialty or location (e.g. local business name, gym that they refer patients to or local hospitals acronyms, e.g. Sick Kids is the Hospital for Sick Children (HSC) in Toronto.
- Track feedback by client, transcriptionist and editor. Note what kinds of errors are happening on the Style Guide, how often they happen and by whom. Provide additional training as necessary.
- Assign clients to a particular pool of transcriptionists and a specific editor (or editors) who have good knowledge in the specialty being transcribed.
- Add another level of editing if necessary, especially for poor quality dictations.
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.