Transcription Services Standards

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Policies
Policy: Transcription Services Standards
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 is 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 (Liane Davidson). 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)

HOW TO DICTATE FOR A VIRTUAL / TELEPHONE VISIT

  • Manitoba Health requires clinic letters to include time and date details on all visits conducted virtually (e.g. telephone follow-up due to COVID-19).

State the following information:

  • Your full name.
  • If you are a resident, state the name of your attending.
  • Patient’s first and last name – Spell it out.
  • Hospital MRN, PHIN, MHSC number, and date of birth.
  • Virtual / telephone visit date, start time and end time (e.g. “November 3, 2020 from 2:30 to 2:45 p.m.”)
  • If you have more than one clinic location, specify which one.
  • Who the letter is to be addressed to. Specify the recipient’s first and last name, not just the surname, and identify which clinic (e.g. “This letter is to Jane Smith-Jones, Nurse Practitioner, at ACCESS Transcona.”)
  • Any additional copies: “Copies to Dr. Fred Doe at St. Boniface Department of Cardiology, and to the Victoria General Hospital Adult Medical Clinic.”
  • This change is being made because patients are not physically on site, unit clerks are not entering their demographic information, and medical transcriptionists therefore have no information on the patient because it has not been entered into the system. This is particularly a problem with new consults, where there are no previous documents to refer to.

PDAT - PROVINCIAL DICTATION USER INSTRUCTIONS

  • A physician receives a billing ID number from the Provincial Medical and Administrative Office (PMAO) office. This is assigned when the onboarding process is complete.
  • The physician then completes a registration form provided by the Department, which is emailed to the Service Desk with the subject line “PDAT install for physician dictation.”

All users of the central dictation system must be registered and have their own user ID number. Do NOT give your user ID number out for others to use.

HOW TO DICTATE USING THE TELEPHONE

  • Dial (9-)204-926-3600 to access the regional dictation system,
  • Key in your user identification number (your billing number), followed by the # key.
  • Enter the site number (see list below), followed by the # key. HSC Department of Medicine is site 13.
  • Key in the worktype number, followed by the # key. DoM day clinic letters are worktype 53.
  • Key in the patient Health Record Number (HRN), including all leading zeroes (e.g. 001234567 rather than 1234567), and press the # key.
  • You will hear a short beep. You are now in ‘Record’ mode.
  • State the following information:
  • Your full name
  • If you are a resident, state the name of your attending.
  • Patient’s first and last name – Spell it out.
  • Visit date. If you have more than one clinic type or location, specify which one.
  • Who the letter is to be addressed to. Specify the recipient’s first and last name, not just the surname, and identify which clinic (e.g. “This letter is to Jane Smith-Jones, Nurse Practitioner, at ACCESS Transcona.”)
  • Any additional copies: “Copies to Dr. Fred Doe at St. Boniface Department of Cardiology, and to the Victoria General Hospital Adult Medical Clinic.”
  • Dictate doses using individual digits: Say “one six” for 16, and “six zero” for 60.
  • Most transcriptionists do not have access to the patient chart for reference, so please state numbers, dates, dosages, names, etc, clearly.
  • PAUSE/RECORD Press 2 to pause (you will hear an intermittent tone); press 2 again to resume dictation (you will hear a single tone).
  • REWIND/PLAY Press 3 for a short rewind with automatic playback.
  • FAST FORWARD Incremental forward; press 3 to release fast forward. Press 44 to fast forward to the end of the dictation.
  • REWIND Press 7 for incremental rewind; press 3 to release. Press 77 to rewind to the beginning of the dictation.
  • END CALL Press 5 or 9 to complete the report, obtain a dictation job number (a seven digit number that uniquely identifies your dictation and allows it to be tracked), and disconnect from dictation system.

SITES USING THE PROVINCIAL DICTATION SYSTEM

  1. Health Sciences Centre
  2. CancerCare MacCharles
  3. CancerCare St. Boniface
  4. Concordia Hospital
  5. Riverview Health Centre
  6. Deer Lodge Centre
  7. Misericordia Health Centre
  8. Kildonan Medical Centre
  9. WRHA Community Services
  10. Victoria Hospital
  11. Grace General Hospital
  12. HSC Department of Medicine
  13. VGH Adult Medicine Clinic
  • Number 20 for site location Misericordia Sleep Disorder Centre

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