Transcriptionist EMR

We are trying to find information about a transcriptionist entering information into EMR and how that might impact meaningful use? The transcriptionist is not a licensed medical professional and we have always thought that they must be in order to meet the meaningful use requirements.

Comments

  • edited May 2017
    Is the transcriptionist somehow serving as a scribe for the physician and identifying themselves in the documentation as a scribe?

    Don


    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
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  • No they are not acting as a scribe as they are not in the room with the patient inputting information as directed by the physician. They are given either a tape or handwritten information to enter into the EMR system.
  • edited May 2017
    If they are simply transcribing the dictation and it is being signed off by the physician, it should qualify as physician documentation.

  • edited May 2017
    I may not be understanding your question completely, but just from personal experience with a clinic that I work with, this was an issue.
    If the physicians did not go in and create the document in the EMR and go through the edits first to capture the meaningful use data, then we could not pull that information, so we require that they do this and start the record, then the transcriptionist can go ahead and just upload the office visit documentation into that record that the physician has already started and once all data is entered and the record is complete the provider can electronically sign off on that record.

    So, if the edits are set up in your EMR this way to capture meaningful use data entered by a licensed medical professional; then just by having the transcriptionist uploading the physicians documentation after transcribed, will not capture meaningful information. Unless the physicians are transcribing all of the meaningful use information too, but then I don't know how you would track that in your EMR without going into each chart and manually doing so.

    Donna De Boer, CPC

  • A large hospital sponsored group of physicians uses 'google' glasses to dictate their notes per encounter. They are transcribed (away from the treatment room) and placed in the EPIC system. Since as Lori suggested, the individual that actually 'puts' the dictation into the medical record is merely a transcriptionist very much like in the old days when the docs dictated their note and someone else transcribed them.
    Maxine



    Maxine Lewis, CMM, CPC, CPC-I, CCS-P, CPMA
    Main: 513-771-7070
    Direct: 513-672-4363
    Fax: 513-326-7640
    200 Northland Blvd
    Cincinnati, OH 45246
    mlewis@scrogginsgrear.com
    www.scrogginsgrear.com

  • edited May 2017
    I think the tricky part with MU is the ordering part of meds, labs and radiology orders. I believe as long as these are put in by a scribe but signed off by the provider these meet criteria for MU.
    Beth



    Happy Connecting. Sent from my Sprint Samsung Galaxy S® 5


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