Transcription Services

From U of M Internal Medicine Wiki
Policies
Policy: Transcription Services
Policy Nr: Sec 10 - 03
Target Review Date: 2017-12-31
Main Stakeholder: Transcription Manager

Purpose

The Department of Internal Medicine provides quality transcription services for ambulatory care visits and diagnostic services for part-time and full time physicians, GFT and non GFT using the Provincial Dictation and Transcription System. The goal is to provide a forty-eight (48) hour turnaround time from date of upload with an average accuracy score of no less than 98% for minor and major errors and 100% for critical errors.

A critical error is one that potentially compromises continuity of care, such as medical word misuse or omitted dictation. A major error one that compromises the integrity of the document without risk to patient care, such as misspellings, most demographic errors and formatting errors. A minor error is one that compromises neither patient care nor documentary integrity but represents an area of recommends improvement to the transcription, such as capitalization, punctuation and other minor style and grammar errors.

Policy

Letters shall be dictated within one week of the date of the ambulatory care visit by the attending physician. Interpretation for diagnostic services shall be dictated within five (5) working days of the date of the service by the attending physician.

All letters will be transcribed, in the Provincial Dictation and Transcription System system, on a first in/first out basis. Requests for Stat letters should be made directly to the Transcription Manager (Cathy Belanger). The letter will be provided within four (4) hours of the request. Priorities can also be marked as such when dictating. Only department-approved letterhead will be used. Letters will be dated the clinic visit date. At the bottom of each letter, the date dictated and date typed will be shown. (See also Transcription Services Formatting Standards - Consultations and Letters of Correnspondence)

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