The Dilemma of Paramedics and a Practical Solution
Paramedics are so busy that they hardly find time to type out a clear narrative of the patient encounter. So, very often problems such as the following crop up in their PCRs and create issues for physicians.
- Treatments entered out of order
- Short and incomplete narratives
- Many abbreviations that are difficult to understand
- Misspelled words and poor grammar
Even though most paramedics deliver outstanding care and service, it is not reflected in their hastily written PCRs. South Metro's officers were determined to lighten the workload of the paramedics and they decided to borrow the strategy used by most doctors - that of using the service of a reliable medical transcription company. They soon found that the paramedics who dictated their PCRs instead of typing them provided excellent patient care reports that the doctors could easily understand and go on to provide the right care. The dictated reports could be easily followed and there was a lot more subjective information.
Transcripts Provided in Any Required Format
South Metro's paramedics typically use the CHART (chief complaint, history, assessment, Rx/treatment, transport) and SOAP (subjective, objective, assessment, plan) formats. The SOAP format is a highly structured format for documenting the progress of the patient during the treatment that can be used by the healthcare professionals at the time of future visits. The "subjective" part provides the medical history of the patient, current condition, the description of discomfort, presence of nausea or dizziness etc and is recorded in the patient's own words. The "objective" section includes all objective elements of a patient's analysis such as vital signs, findings from physical examination, laboratory results, weight, height and age of the patient and so on. Based on the subjective and objective details, a Problem Oriented Medical Record is generated. A POMR is data that is easily accessible and also encourages ongoing assessment and revision of healthcare plan by all members of the healthcare team. It includes all information about the health assessment of the patient. In short, it is the analysis of both subjective and objective data of a patient's record. Then there is the "Plan" section where the doctor outlines the plan of action for the patient and it also includes follow up visits and the treatment provided. In short it is the treatment plan that is already in effect.
Whatever the format required, medical transcriptionists can provide the transcripts in that format with remarkable accuracy.
The Transcription Process
The dictation could be provided via a phone number; the paramedics dial a dedicated phone number and enter a personal code. Their dictation is recorded by a computer system. This recording is sent to a transcriptionist who would transcribe it into a typed narrative which would be edited and proofread for accuracy and precision. The paramedic then logs into the transcription company website and copy-pastes the narrative into her PCR.
- The entire process would take less than an hour from the start of the phone call to the finished narrative being sent to the paramedic.
- Paramedics can choose to use abbreviations or speak in plain English. The transcriptionists will expand the abbreviations into full words so that there is no confusion or ambiguity involved.
- A dedicated transcription team is assigned to each group of providers so that they get accustomed to that provider's dictating style.
A Burden off Their Shoulders
The paramedics say that dictation enables them to get the basic facts on the record before returning to service after a call. This was something they could hardly achieve with typed narratives. Medical transcription companies continue to play a vital role in the present EHR era improving the way doctors, paramedics and other clinicians function. With HL7 interface and EHR-integrated transcription capabilities they provide a rewarding experience to healthcare providers, while also adding the much needed human touch.
MTS Transcription Services (MTS) is committed to providing clients with professional and reliable transcription services for all major medical specialties and sub-specialties.