Medical transcription is interesting and challenging. Patient documentation that was always handwritten on paper was transformed when dictation could be easily captured and audio files shared with a transcriptionist to document. Today, the widespread increase in the utilization of speech recognition (SR) technologies at the point-of-care has changed the role transcription plays in the documentation process.
Yet, the ability to accurately capture medical records by SR engines and algorithms has long been debated. In a study published by the JAMA Network, 217 clinical notes were randomly selected from two healthcare organizations. There was a 7.4% error rate in the version generated by speech recognition software, a 0.4% error rate after transcriptionist review, and a 0.3% rate in the final version of the documentation signed by physicians. SR technology may sound promising, but the errors created due to grammatical, syntax, homophones, and other interpretive mistakes can inadvertently result in inaccurate and incomplete medical documentation. These results demonstrate the need for human review, quality assurance, and auditing as part of the clinical documentation process.
What’s worse, those errors can have serious implications for downstream patient care and well-being. Not to mention, they can be quite costly further down the line in terms of quality management and compliance, billing denials, and even litigation or a potential facility shut down for non-compliance. Medical transcription and editing play a key role in resolving those errors before they become a problem for providers and patients.
So how do you avoid transcription mistakes? Well, first, you have to know what the biggest and most common transcription mistakes are. Once you know that, you’ll have an easier time avoiding them.
Why Transcription Mistakes Happen?
Like other forms of text, medical documentation created using SR technology — directly by a physician or via dictation — should be edited and reviewed for syntactical (order of words), semantic (denotation and connotation), jargon-related, and technical errors.
Transcription mistakes happen for several reasons:
- Poor audio quality, which makes it hard for the transcriptionist to understand the recording and transcribe it correctly
- Not following formatting standards for dictated reports
- Lack of experience or proper training in transcription or medical terminology
- Words that sound similar but have different meanings
- Not proofreading the finished transcript
Top 8 Biggest Transcription Mistakes
Here are the eight biggest mistakes that can happen during transcription.
1. Typing Errors
Typos happen to anyone. They happen when you press the wrong key. For example, a common typing error is typing “buisness” instead of business.
2. Atomic Typos
Atomic typos are easy to miss but can have a pretty catastrophic impact on the finished transcription. Those are one-letter mistakes where you end up typing a word that exists but has a completely different meaning than the word you wanted to type.
Naturally, the spellchecker will miss those words because they are still existing, correctly written words. But you might end up changing the meaning of the sentence entirely.
Atomic typos can include typing peace vs. piece or cavalry vs. calvary. It can also involve omitting a letter entirely. For example, omitting the letter r in country results in typing county.
3. Mishearing words
Another common transcription mistake is mishearing words. As a result, you end up using words incorrectly. For example, you hear the word game instead of name. Similar to atomic typos and typing errors, misheard words can change the meaning of the sentence or, worse, make no sense.
4. Words That Sound The Same
Words that sound the same are called homophones. They are often the most common transcription mistake. For example, typing its when it should be it’s.
A few examples of homophones include:
- They’re, their, and there
- You’re and your
- Wear and where
- To, two, and too
- Brake and break
- Loose and lose
- Knot and not
- And more.
5. Misspelled Names
Names can be spelled in many different ways. For example, Ashley or Ashleigh, Lesley or Leslie, MacGregor or McGregor. To avoid this mistake, it’s best to look up names of people, cities, company and brand names, and any other name online. It’s also a good idea to refer to your patient’s records and double-check all the names to ensure proper spelling.
6. Spelling And Grammar Mistakes
Spelling and grammar mistakes are pretty common. Luckily, there are a number of tools that can help you eliminate and correct those as you’re transcribing the recording. A spell checker is built into most transcription platforms as well as MS Word and Google Docs. You can also use a tool like Grammarly to check your grammar, spelling, style mistakes, word choice, and more.
7. Shortcut Mistakes
Using shortcuts can save you a lot of time and help you produce transcriptions faster. But, they can also lead to errors, especially if you turn on the autocorrect features.
8. Speech Recognition Mistakes
While it’s true that speech recognition software is getting better every day, it’s still not perfect. As a result, it’s more error prone than human transcription.
Five Tips For Avoiding Transcription Mistakes
So, now that we’ve covered the most common transcription mistakes, let’s take a look at how you can avoid them.
1. Proofread Everything Twice
The most important tip for avoiding common transcription mistakes is proofreading the finished transcript and then proofread it again. Ideally, you should proofread the text for only one error at a time, which means your transcript will need multiple proofreading sessions. You can also try reading your transcript out loud or reading it backward, as this can help you catch spelling mistakes.
2. Invest In High-Quality Audio Recording Equipment
As mentioned earlier, transcription errors happen because of poor audio quality or misheard words. To avoid those mistakes, you should invest in high-quality audio recording equipment.
Such equipment can include using an external microphone instead of the one built into your computer, a lapel mic that’s connected to your phone, a land-line instead of a cell phone, or even buying a highly rated voice recorder.
3. Create Templates And Checklists
Create templates and checklists for yourself as well as for the rest of your medical staff that they can follow during the dictation process. These tools will provide structure for your dictations and ensure that nothing gets left out.
4. Disable Autocorrect
If you’re using your phone or computer for voice recording, disable the autocorrect features. Autocorrect can be a source of common transcription errors while you’re recording your voice as well as while you type. Autocorrect can be turned off in Settings > Devices > Typing in Windows. To turn it off on Mac computers, go to System Preferences > Keyboard > Text.
5. Consider Outsourcing Your Transcription
Our last tip is to consider outsourcing your transcription to professionals. A professional transcription company will have the necessary language skills, medical knowledge, and relevant experience. They will also have proper training.
They will be able to take your recorded notes and turn them into high-quality transcripts, or review and edit speech recognized documents, to produce accurate medical documentation.
Ultimately, outsourcing your transcription will save you both time and money, not to mention it will alleviate a majority of workplace stress so you can focus on providing better care for your patients.
Final Thoughts
Transcription errors are not uncommon. They happen for a variety of reasons, such as because the audio recording wasn’t clear enough or because the speech recognition software was unable to correctly interpret all the words.
Use the tips in this article to avoid the common transcription errors and produce accurate and complete documentation.
