MEDICAL TRANSCRIPTION QUALITY GUIDELINES BY HPI
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HPI Standards are the quality check guidelines for improving the quality of medical transcription. Quality check parameters and computing system provides 100% quality satisfaction and highest accuracy levels.
HPI GUIDELINES are categorized in following sections:
Error 1: Medical Word Misuse - 1.00 Point
This category is given the highest number of negative points because of seriousness of its consequences. E.g., a wrong disease can be attributed to a patient and could be carried in the medical record for life, causing incorrect treatment and medical decisions as well as inaccurate billing of the patient's account. If the same misuse is repeated throughout the entire report, it is counted as only one error in that report.
Creative Medical Transcription is also included in this category. This refers to "making up" dictation (words and/or phrases) when what is dictated is not clear.
Error 2: Omissions (Omitted Dictation) - 1.00 Point
This category is given the highest number of negative points because of seriousness of its consequences and its reflection on lack of professional concern and ability of the medical transcriptions. If the medical transcriptionist cannot understand what the dictator is saying, it can be due to the poor dictation quality or lack of knowledge on medical transcriptionists part. Help must be sought and a resolution reached, including leaving a blank and asking the dictator for the information.
E.g.: omission of an entire laboratory finding because the value itself could not be heard; deleting negative or normal findings; or omitting entire sentences because the main part of it could not be understood. This category does not apply to inconsequential missing words such as articles or conjunctions. Clipped sentences are allowed if it reflects the dictator's style. This error category is meant to apply to purposeful and/or serious omissions.
Error 3: Medical Word Misspelling - 0.75 Point
This category is self-explanatory.
Error 4: English Word Misspelling or Misuse - 0.75 Point
This category refers to errors that have more serious consequences, such as nouns, verbs, or important qualifying adjectives and adverbs (e.g. elicit/illicit, dissent/descent). For errors of lesser consequence,
see Error #7.
Error 5: Inappropriate Blanks - 0.75 Point
This category refers to blanks left which, through research, the medical transcriptionist could have resolved. The purpose of this category is to limit abuse of blanks for the sake of speed, or for higher line counts in a production environment.
Error 6: Grammar Errors - 0.50 Point
Grammar errors include the following -
• Subject-verb agreement.
• Correct use of medical abbreviations.
• Use of proper parts of speech (e.g. laying/lying).
• Use of proper words (e.g. recurrence instead of reoccurrence).
• Incorrect use of nouns and adjectives.
• Use of proper singular or plural nouns, positioning modifiers correctly, use of correct verb tense, correction of redundancies and inconsistencies, and editing slang or inflammatory remarks when appropriate.
Error 7: Punctuation Errors - 0.50 Point
Punctuation errors at this error level include colons, semicolons, and quotation marks. The reasoning is based on the effect these rules can have on the meaning of the sentence if misused.
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Error 8: Typographical Errors and Miscellaneous (Minor Grammar, punctuation, or Omission Errors) - 0.25 Point
Errors at this level include the following -
• Periods within abbreviations
• Correction of run-on sentences
• Grammar or omission errors that do not seriously effect the dictations meaning
Error 9: Formatting Errors - 0.25 Point
This error refers to the prevailing departmental/physician guidelines for placement of certain information within the document. E.g. Headers, Footers, templates as defined by the client.
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Quality Evaluation (QE) Example
Pick a sample report and calculate the total error value