Accuracy in Medical Transcription – A Point that can Save a Life

No one would dispute that accuracy in medical documentation is vital.

Generally, typing accuracy is calculated by the number of correct entries divided by the total number of entries, and then multiply by 100 to get a percentage.  For those who like formulas,

Accuracy = (1 – # errors) x 100

We’ve looked at this calculation, and how it is used in the calculation of typing speeds in another blogpost.

However, when dealing with medical documentation, errors are not just inconvenient, they can be outright dangerous to the patient.  So a different formula is used to calculate typing accuracy when it comes to medical documents.

In this formula, errors are assigned a “point value”.   A critical error is given a higher ‘point value’ than a minor error.  And the expected degree of accuracy is 98%.

To calculate the ‘point value’ of errors, the ADHI generated a scale of what was considered unacceptable.

  • Critical errors – 3 points
  • Major errors – 1 to 1.5 points
  • Minor errors – 0.25 to 0.5 points
  • Administrative/Educational – 0 points

In 2017 this scoring system was reviewed to remove the Major Error category, with items within that been either being promoted to a Critical Error or redefined to a Noncritical Error Category worth 1 point, Minor errors and Administrative/Educational errors remain the same.

There are two methods of implementing this system, and it should be up to the individual organisation to determine the one that best meets the needs of their business.

Method 1:  Error from 100.

A very simple calculation where every error is multiplied by it’s relative ‘point value’ and deducted from 100.  Therefore one critical error will mean the document fails the QA assessment.

Accuracy = 100 – ((#  x point value) + (#  x point value) + (#  x point value) + …)

Method 2:  Errors by number of lines

This method takes into consideration the length of a report, as well as.  While a relatively short report of only 20 lines will fail QA assessment the first method, so too will a report of 200 lines which is otherwise faultless.  This second method factors in the length of the report.

Accuracy = (100 – (#  x point value) + (#  x point value) + (#  x point value) + …)) ¸ # lines typed

 

Now you know the formulas, let’s look at the definitions for each of these error categories.  In summary:

A critical error is one which

  • Adversely impacts on patient safety
  • Alters a patients’ care or treatment/
  • Adversely impacts the accuracy of coding and billing
  • Results in a HIPPA violation
  • Adversely affects medicolegal outcomes.

Some example of this would include things like incorrect terminology which alters or obscures or is opposite to the intended meaning (hypo-/hyper-, known/no, regular/irregular), incorrect medication (including name, dose/dosage, unit of measure and method of administration), incorrect side/site (left/right, peroneal/perineal), use of unapproved abbreviations, omitted or inserted (“note bloat”) text, failure to flag critical inconsistencies/discrepancies, use of confusing words/phrases.

A Noncritical error impacts on document integrity but does not have the potential to affect patient safety, care or treatment.

Examples would include incorrect spelling of medication or terminology, punctuation that alters/obscures meaning, nonsense text, incorrect medical homophones, and failure to follow the Style Guide or individual account specifics.

Differentiation between Minor and Administrative/Educational errors are at the discretion of the organisation.  Companies may choose to limit the number of Repetitive Educational errors within a report, or may upgrade repetitive educational feedback as a minor error.

These would include things like grammar/punctuation/misspelling (other than mentioned above), capitalisation (e.g., generic drug names if required by account specifications), incorrect English homophones.

A couple of final points of clarification.

  • With the increasing number of clinician-generated documents, these errors can also be ascribed to the clinician, rather than to the healthcare documentation specialist alone.
  • When assessing the accuracy of your transcriptionist, you also need to take into account the additional skills required to that of a typist. Another of our blogposts discusses these differences.
       

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Annaliese Arndt
Phone 0407 237 103
annaliese@mytypingservice.com.au

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