The Medical Transcriptionist's Role With The Healthcare Record

The healthcare record is: -Chronological -Documentsregulations for reimbursement and third-party payer
of a patient's initial database -Initial evaluationrequirements. The healthcare record is kept for legal
-Identified problems and needs -Objectives of careprotection for: -The medical care facility -The patient
-Prescribed treatment -Results The healthcare record-The staff -The physician The healthcare record can
belongs to the hospital, medical facility or officebe used for: -Research -Compiling statistics
where it originated. It cannot be removed from the-Evaluation of healthcare delivery The healthcare
premises without a subpoena or court order.record originates: -In the admissions department of
Although much of the healthcare record is maintainedhospitals -Outpatient registration -Emergency
through computer software systems, most medicaldepartment -Private physician facilities reception area
care facilities still maintain a "paper" healthcare recordThe major role of all departments of healthcare
of some sort. The healthcare record is maintained byrecord origins is to: -Collect patient identification and
the Health Information Department of hospitals anddemographic information -Correct spelling of patient's
medical facilities and usually headed by a registeredlegal name and birth date is critical The information
record administrator or an accredited recordcollected is used to assign healthcare record numbers
technician. A former term for the healthcare recordand is maintained for the lifetime of the patient. It is
for over fifty years was "Medical Record." The newvital that the medical transcriptionist transcribe the
term of healthcare record denotes both illness andidentification and demographic information concerning
wellness. The Medical Record Department name hasa patient with complete accuracy as well as all other
also changed to Health Information Department.physician dictated reports. A transcribed incorrect
What is the purpose of a healthcare record? It is adate of birth or patient number can produce chaos in
measurement and documentation of care rendered inthe Health Information Department and throughout
a medical facility. The healthcare record is used tothe medical facility. This article is FREE to publish with
plan, communicate and evaluate the quality of carethe resource box. © 2007 Connie Limon All
given to each patient. It provides "proof" of workRights Reserved
done for each patient. Documents are required toConnie Limon, Medical Transcriptionist. Visit us at for
meet federal, state, and JCAHO (Joint Commissionmore information about the unique and rewarding
on Accreditation of Healthcare Organizations)career choice of Medical Transcription. Visit Camelot
standards and regulations. In addition the documentsArticles for a variety of FREE reprint articles for your
contained in a healthcare record must meetnewsletter, web sites or blogs.