Medical Transcription

In the United States there has been a movement for Emergency Doctors to record the patient visit by using a charting system called the T System. This is one of many check off template systems that have gained huge popularity for the reasons of convenience and ease of use, resulting in replacement of dictation services in many emergency departments. I believe that these systems undermine the goal of charting. As I see it these are:

1. A record to enable future Doctors and care givers to understand what took place at the time of the patient’s arrival into the hospital.
2. To enable a legal document which can record the thought process of the Doctor atthe time of patient consultation.
3. A document from which healthcare finances can be organised.

Arguments are made in favour of tick box templates and that the record isimmediately available for future health carers. In contrast to dictations can take some time to come back after transcription. But the real reason for template use within Emergency Rooms in the US and perhaps in the UK, is that it is much cheaper thandictation and is also easier,  as the skill of dictation is not learnt by Emergency Room Physicians. My concern, however, is that tick box templates may result in an inaccurate record of what happened. I worry that medical staff will get used to ticking all the boxes without actually taking time to accurately process the examination just completed. Some of the template schemes I have seen do not have enough space next to the boxes in which to put an elaboration on the physical exam. It may also be that the incorrect box is inadvertently ticked. However, most importantly, such a brief record of a patient visit leaves almost no memory of the patient within the Doctor’s mind and this can have medical legal consequences if the chart needs to be reviewed sometime in the future as the Doctor will have a very poor record of his thought process at the time.The ideal system would be to have some combination of a charting systems. Here the doctor is prompted so that he does not forget certain exams and the chart also leaves adequate space for elaboration which could be filled in via dictation in predetermined zoned areas. Dictation works by also enabling thought processes to be conveyed in a legible manner. It is frustrating to try and read the illegible scribbles written on a chart by time pusheddoctors with poor penmanship.

In conclusion, I believe that dictation of charts enables continuity of care, medical legal defence and appropriate costings to happen in a smoother and more efficient manner which in turn creates cost savings that eclipse the up front higher costs ofthis process.

There are various ward jobs that pick their time. It wasn’t so long ago that I was a newbie on the wards and moments of head in hands peace could only be snatched behind the bolted door of a lavatory or in a badly lit part of the ward. Without exception it was exactly this time that the bleep would go off and, eventually struggling to a nearby telephone I would hear my registrar ask- ‘So, got the xrays for the xray meeting yet?’There are plenty of daily hospital administrative tasks, but none more so arduous as preparation for the xray meeting. The xray department was always found in the basement of any hospital and in amongst the rows of stale xray envelopes would be found some anaemic looking student, posted for the summer. It was his job to look for my long list of xrays and his job to put up with the groans and tuts when they couldn’t be found. This was inevitable. X-ray packets were empty, the wrong x-rays were in the packet, or only half the films were there. The long list of imaging for various patients soon dwindled to two or three complete packets, and my arrival at the xray meeting would be met by my registrar’s disappointment. Not only had I failed but of course it was my fault.

This may have seemed like a minor misdemeanour, but the inability to have imaging ready, reported, and properly consulted on only struck me when I started to be run clinics. The absence of the crucial x-ray result meant another anxious week’s wait for the diagnosis. That ‘mass’ in the liver, which could be a cancer would have to wait until I could find the imaging, or the report or both.And then the dawn of PACS. It would be easy for me to sound like a trumpeter for government policy but the truth is that the advent of PACS has had a huge impact on the way hospital medicine is practised. Hospital medicine, especially for in-patients, needs to move away from diagnosis to treatment. Diagnostic tests are improving steadily in accuracy and speed and as such, the diagnosis should make up only a fraction of the patient’s time with the doctor. If I have a problem, i want to know the cause quickly, and then start treatment. Getting a diagnosis is not just about doing tests, but also about the availability of information. I want to know exactly when this liver cyst was found and where it was- has it grown from a previous scan; does this tally with the blood results? As such good information needs to be available quickly. This is what PACS provides- the universal availability about a patient’s radiology so intelligent decisions can be made. I now can tell what scans were performed when on every patient from anywhere in the hospital. This makes the art of diagnosis a much easier and more precise one. I can also educate myself about aspects of imaging as well as show the patient zoomed in images and allow them to visualise their problem. And of course medical students can learn more about these important diagnostic tests (or just change the image’s contrast so it look like the head CT just shows an empty cranium amongst hoots of laughter-an accomplishment of our last medical student).

Of course, the celebration needs to be guarded. There are problems. I can’t see the CT scan of a patient who had the test at another hospital without getting hard copies (and with choose and book at patient’s care is increasingly likely to be disseminated). Worse still, if a patient has a severe head injury, I have to courier the scans to the regional neurosurgical centre with the possible delay of hours for emergency surgery. Now that the technology exists to distribute imaging this problem will need to be solved. I have faith that these largely networking problems can be overcome and the sooner the better. These are the dots that need to be joined to provide a genuinely complete and useful imaging system. For the moment however I’m impressed by the impact of PACS at a local level, but never so impressed as the junior doctor who’s information gathering burden is made ever lighter.