The rules to modifying the Patient Record should be strong foundation for the enterprise seeking to develop policies and procedures. In order to ensure the admissibility of the medical record as evidence, the enterprise must first establish policies and procedures that address

• Author authentication
• Medical record access control
• Medical record archiving and retention
• Medical record security
• Medical record disaster recovery policies and procedures

By establishing controls over the creation of medical records, enterprises can ensure the nonrepudiation of corrections, revisions, additions, and addenda made in the normal course of business.

Ultimately, by controlling the how, who, where, and when of creating the medical record, the enterprise establishes the methodology for performing valid corrections, revisions, additions, and addenda.

The best practices of a healthcare enterprise can develop an effective and valid policy and procedure for the correction, revision, addition, and addenda of health information contained within the medical record.

The key characteristics of an effective policy and procedure include

• Author authentication and accountability
• Clear indication of correction or amendment date and time
• Policies and procedures that prevent unauthorized alteration of documents
• Clear delineation of parent document
• Clear delineation of corrected or amended document
• Notification of health information recipients when amendments and corrections occur
• Retention of the parent document for historical reference

Though it is true that no single rule that addresses medical record correction and amendment exists, enough guidance is available to allow healthcare providers to develop a workable policy and procedure to address the creation of valid medical record corrections and amendments.

A medical transcriptionist should be good at knowledge, skill and ability. To make good money or salary you should be have following 10 qualities.

1. Basic knowledge of medical terminology, anatomy, and physiology, disease processes, sign and symptoms, medication, and laboratory values. Knowledge of specialty (or specialties) as appropriate.

2. Knowledge of medical transcription guidelines and practices.

3. Proven skills in English usage, grammar, punctuation, style and editing,

4. Ability to use designated professional reference materials.

5. Ability to operate word processing equipment, dictation and transcription equipments like foot pedal.

6. Ability to work under pressure with time constraints.

7. Ability to concentrate.

8. Excellent learning skills

9. Excellent eye, hand and auditory coordination.

10. Ability to understand and apply relevant legal concept (e.g. confidentiality)

Date Dictated and Date Transcribed

These dates should be recorded to monitor dictation and transcription patterns as well as to provide documentation of when the work (dictation or transcription) was done. Some dictation and transcription systems are specially designed to automatically record these dates.

Health care reports are, among other things, legal documents. As part of risk management, dictation and transcription dates should be entered accurately and should not be altered.

Capitalize D and T and follow each by a colon and appropriate date, using numerals separated by virgules or hyphens.

Some facilities prefer to use six-digit dates and others, eight-digit. All these styles are acceptable.

D: 4/18/00
T: 4/19/00

D: 04-18-00
T: 04-19-00

D: 04/18/2000
T: 04/19/2000

Note: ASTM’s E2184, Standard Specification for Healthcare Document Formats calls for identification of the place of dictation as well.

When the month, day, and year are given in this sequence, set off the year by commas. Do not use ordinals.

She was admitted on December 14, 2001, and discharged on January 4, 2002. not ...January 4th, 2002 (4th is an ordinal)

Do not use commas when the month and year are given without the day,
or when the military date sequence (day, month, year) is used.

She was admitted in December 2001 and discharged in January 2002.

She was admitted on 14 December 2001 and discharged on 4 January 2002.