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Have You Read Your Medical Record?

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Modesto, Calif. -- Medical transcriptionists are reaching out to the American public to raise awareness about the critical connection between accuracy in the medical record and patient safety during their 21st Annual National Medical Transcriptionist Week.

   “In general, the public is ill-informed about their medical record and the role medical transcriptionists play in ensuring quality documentation,” stated Peter Preziosi, PhD, RN, executive director of the American Association for Medical Transcription.

   “Our goal is to urge consumers to become more involved in their own care by requesting a copy of their medical records to make sure that the records are accurate and represent their care histories.” Preziosi said. “We feel it is our responsibility to educate the public about quality in patient care documentation and the professionals who work to ensure it, medical transcriptionists.”

   The association has developed a checklist to assist the public in requesting copies of medical records and checking them for accuracy. The checklist will provide key things to look for in the record which may or may not have been documented appropriately.

   Since errors in the medical record can lead to inappropriate treatment and care, often with disastrous results, AAMT believes that patients need to be more engaged in ensuring that their care has been recorded accurately and aware of the team of professionals, including medical transcriptionists, who ensure that accuracy.

   “This is a risk management issue,” states Kim Buchanan, CMT, FAAMT, 2005 President of AAMT. “It is important for the public to understand that there is a direct link between accurate documentation and continuity of care. This isn’t about typos or misplaced commas -- this is about critical medical errors, perhaps in the dosage of a medication or documentation of a patient allergy. These are the kinds of errors that patients need to be aware of -- the kind that medical transcriptionists are trained and certified to recognize.”

   Patients can find out more about requesting medical records and checking those records for accuracy at www.aamt.org.

   The American Association for Medical Transcription has been the professional organization representing medical transcriptionists since 1978. AAMT sets standards of practice and education for medical transcriptionists, administers a certification program, has established a code of ethics and advocates on behalf of the profession. There are over 135 component associations of AAMT, each of which holds regular educational meetings and symposia. For more information, visit www.aamt.org.
 

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