Sanitarium

Audience/Purpose:
For those interested in an allied heath profession – a non-medical aspect of the medical field, this definition is to clarify any misunderstandings or confusion about this [nearly self-explanatory] term.

Introduction
Medical Transcription is quite literally the transcription of a patient’s medical history. The process of medical transcription actually started off in the manufacturing industry. The first process was called Manufacturing Resource Planning (MRP) in 1975. This process was taken into the medical field after the transition to electric typewriters, word processors and computers. Today, Speech Recognition software (SR) is becoming overly prevalent in replacing MT’s, but Medical Transcriptionists will always be needed as editors since SR cannot be 100% correct every time. And since many physicians still use short-hand in their notes, transcriptionists that understand the language will be needed to assist the SR in interpreting the notes.

What Is?
Medical Transcription is an allied health profession; which literally deals with the direct transcription of medical data from voice-recorded reports as dictated by physicians/ other healthcare professionals into text format. Since most physicians, in both hospitals and private practices, do not have a lot of time, they tend to voice-record their notes and have transcriptionists later convert them to either electronic or physical hard copies. Most hospitals prefer electronic copies due to its ability to provide immediate access to subsequent departments or providers regarding the patient’s care. Also, the sheer volume of patients and the accompanying paperwork is becoming overwhelming.
Medical Transcriptionists can be onsite, working at the hospital, telecommuting employees for the hospital that do most of their work at home, or telecommuting employees that work as contracted MT’s that perform their work offsite from the hospital/clinic/physician group/ other healthcare provider. Some private practices also decide to directly employee a Medical Transcriptionist on site their own offices.

Today’s MT
The job of a medical transcriptionist is ever evolving (as long as we keep churning out new and more sophisticated technologies). Today, many MT departments work closely with IS and IT staff to stream voice transcription online – allowing the MT staff to instantaneously begin working on the transcription. This also allows healthcare providers to be able to use their PDAs and PCs (desktops and laptops) to record their notes and have it immediately reach the MT department for transcription
*Headings are not parallel because I find that differences and creativity of headings are more appealing to readers*

Works Cited
Shah, I. (2010, October). Medical Transcription. Retrieved July 2011, from Whatis.TechTarget.com: http://searchhealthit.techtarget.com/definition/medical-transcription-MT

The Healthcare Financing Administration (HCFA) was created as a principal operating component of the Department of Health and Human Services (HHS) in March of 1977. Its purpose was to combine under a single administration the oversight of the Medicare program, the Federal portion of the Medicaid program, and the related quality assurance activities.

Medicare: The Medicare Program provides health insurance coverage for people over the age of 65 and younger people who are receiving social security disability benefits. Beneficiaries of Medicare can receive care either through the traditional fee-for-service delivery system or through coordinated care plans; plans such as health maintenance organizations and competitive medical plans, contracted through Medicare.

Medicaid: The Medicaid Program is a medical assistance program jointly financed by State and Federal governments for eligible low-income individuals. Medicaid covers healthcare expenses for all recipients of Aid to Families with Dependent Children, and most States also cover the needy elderly, blind, and disabled who receive cash assistance under the Supplemental Security Income Program. Some coverage is may also be extended to certain infants and low-income pregnant women. Some States also allow for the coverage of other low-income individuals with medical bills that qualify them as categorically or medically needy.

Quality Assurance: The Medicare/Medicaid programs include a quality assurance focal point to help carry out quality assurance provisions of the programs, the development and implementation of health and safety standards of care providers in Federal health programs, and the implementation of the End Stage Renal Disease Program and the Peer Review provisions.

The American Health Information Management Association is a professional non-profit organization for medical record management. Traditionally working out of hospitals and to referring paper files, the field presently refers to all healthcare systems and types of media. AHIMA’s mission is as stated: “to be the pre-eminent foundation recognized for excellence in health information leadership, policy and research for the healthcare industry and the public.” The foundation formulates and issues opinions, supports education, conducts research, and compiles its contributions into a single Body of Knowledge (BoK).
AHIMA can be traced back to its origin in 1928 when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA). ARLNA’s purpose was to “elevate the standards of clinical records in hospitals and other medical institutions.” In its 82 year history, AHIMA has undergone three name changes; from its original name of ARLNA, it became the American Association of Medical Record Librarians (AAMRL) in 1938; then in 1970 the name was changed to the American Medical Record Associations (AMRA); then finally in 1991, it was given its current name of the American Health Information Management Association (AHIMA). The name changes were justified with an explanation that reflected the progression of contemporary medical record use, practices, and perceptions.
As of 2010, the association has more than 59,000 members in four membership classifications. Each member subsequently belongs to relevant state chapter. The association offers seven credentials pertaining to four areas of practice; HIM, Coding, Data Analysis and Privacy. Two credentials require formal education; the others are acquired by a combination of testing and work experience. AHIMA requires members obtain regular continuing education to maintain their credentials. The Journal of AHIMA has a circulation of 59,000 and publishes both peer-reviewed and non-peer-reviewed articles. The Association’s membership is overwhelmingly female.

The Vision, Mission, and Values of the American Health Information Management Association

The US Occupational Safety and Health Administration is an agency of the US State Department of Labor. The agency is headed by a Deputy Assistant Secretary of Labor. OSHA was created by congress under the Occupational Safety and Health Act signed by President Nixon in 1970.
The mission of OSHA is to help prevent work-related injuries, illnesses, and occupational fatalities by issuing and enforcing health and safety standards in the workplace. OSHA’s federal regulations cover most private sector workplaces. Therefore the OSH Act allows for states to develop their own plans to cover the public employment sector, as long as it provides equivalent protection to that provided by the federal government to the private sector. In return, the federal government pays 20% of the cost for states that have had their plans approved by OSHA.
OSHA’s most notable regulation changes in the last 40 years include:
•Guards on all moving parts (1970)
•Permissible exposure limits (based on standards from 1968): maximum concentrations of chemicals stipulated by regulation for chemicals and dusts
•Personal protective equipment: broader use of respirators, gloves, coveralls, and other protective equipment when handling hazardous chemicals; including goggles, face shields, ear protection in typical industrial environments
•Lockout/tagout (1980s): requirement for locking out energy sources when performing repairs or maintenance
•Confined space (1990s): specific requirements for air sampling and use of “buddy system” when working in small, confined spaces
•Hazard Communication (1983): aka “Right to Know” standard which requires developing and communicating information on the hazards of chemical products used in the workplace
•Process Safety Management (1992): issued as an attempt to reduce large scale industrial accidents. In this situation, process refers to any activity that is in reference to dealing with highly hazardous chemicals in the workplace
•Bloodborne pathogens (1990): a standard designed to prevent healthcare/ other workers from being exposed to bloodborne pathogens, i.e. hepatitis B and HIV
•Excavations and trenches: OSHA requires that any trench or excavations wherein workers are more than five feet deep must be provided with safeguards in addition to proper sloping and storage of excavated material to prevent collapses/cave-ins
•Exposure to asbestos

RIS is a computerized database used [by radiology departments] to store, manipulate and distribute patient radiological data and imagery. The main parts of the system include: patient tracking and scheduling, result reporting and image tracking capabilities. The RIS is a compliment to HIS (Hospital Information System); both are critical to the efficient workflow of a radiology practice.
RIS has several basic functions; ranging from:
•Patient management – RIS can track a patient’s entire workflow within the radiology department; images and reports can be added to and retrieved from EMRs and viewed by the authorized radiology staff.
•Scheduling - Appointments can be made for both in and out patients upon reception of the order. RIS has the ability to place patients in allocated time slots with the proper radiology staff.
•Patient tracking - A patient’s entire radiology history can be tracked (from admission to discharge). This also includes all past, present, and future appointments.
•Results reporting – Statistical reports concerning the results of a single patient, a group of patients or a particular procedure can be generated by the RIS.
•Film tracking – Individual films can be tracked.

Additional features of RIS are important because it allows for radiology departments to be in tune with several other systems being used by other healthcare institutions as well as the hospital the radiology department may be a part of. Thanks to the help of HL7, RIS is able to communicate with it’s HIS counterpart, as well as with PACS and PACS workflows.
RIS’ initial use was in the 1970s; its original purpose was to manage and store radiology information.