(919) 477-5152In the fast-paced world of healthcare documentation, mistakes and addendums are an inevitable reality. From misspeaking errors to late-arriving clarifications, a variety of situations may require modifications to an initial medical transcript. However, the approach to handling these revisions is critical for ensuring full transparency and maintaining legal/compliance standards.
At Fast Chart, we follow rigorous protocols aligned with industry best practices to properly document corrections in a manner that preserves an absolutely clear record. The two primary methods are strikethrough formatting and audio blanking.
What is Strikethrough Formatting?
The strikethrough approach involves leaving the original dictated text intact, but striking a line through the erroneous portion. The correct verbiage is then transcribed immediately following with any amendments clearly indicated.
For example:
“Patient presented with chest pains severe chest pains and shortness of breath.”
This format ensures additions, omissions, or clarifications are tracked in full context rather than being obscured. Strikethrough allows reviewers to see the original transcript dialect as well as the finalized documentation.
When to Use Strikethrough:
– Minor errors or rephrasing requirements
– Adding missing words or information
– Documentation updates from the provider
What is Audio Blanking?
In some cases, a dictator may need to completely remove sensitive or incorrect information from the audio file itself. The blanking method allows transcriptionists to identify and replace portions of the audio recording with blanked sections, removing any potentially improper privacy violations or defamatory content.
For example:
“The patient reported recently traveling to [ ] for [ ] surgery.”
Audio blanking ensures the integrity of the medical record by omitting unverifiable or inappropriate details that should not be transcribed. Empty parentheses [] or placeholders like [REDACTED] are used to indicate the blanked sections.
When to Use Audio Blanking:
– Identifying details that violate HIPAA/privacy
– Inappropriate statements about patients/staff
– Expletives or off-topic commentary
Maintaining Proper Audit Trails
Regardless of which correction method is utilized, it’s imperative that medical transcripts maintain a clear audit trail detailing who made each revision and when. Most transcription platforms include secure permissions, logs, and e-signatures to authenticate the finalized documentation.
At Fast Chart, our quality assurance process involves line-by-line review to validate accuracy in addition to proper handling of any amendments, blanks, or strikethroughs needed. We collaborate with provider organizations to establish mutually agreed-upon policies and formatting templates.
By carefully documenting edits with strikethrough or blanking as appropriate, you can ensure your medical transcripts uphold best practices for preserving transparency, accountability, and patient privacy.