Productivity in Medical Transcription and Documentation – Expand Responsibly

As a healthcare documentation specialist – whether our title is medical transcriptionist, editor, or medical language specialist – our pay may be largely based on productivity.  Often it may seem that productivity becomes front and center – after all, this is our livelihood.  More lines means more money!

Well, yes, BUT (and it’s a big but).  At the risk of sounding preachy, let’s not forget that our first responsibility is to the patient and ensuring that the information we are documenting for them is accurate.  Look at it this way:  Sometimes, you are the patient.  How do you want the healthcare documentation specialist to treat your record?

Fear not.

There are ways to maximize productivity without sacrificing quality, and vice versa.  Efficient use of references and research skills, reducing interruptions, taking rest breaks, and having an ergonomically sound workstation are all important.  There is one tool, however, that most specialists use or rely on in some way – the expander program.  This can be either through the use of the automatic text features in word processing programs, through the expanders/normals feature of a documentation platform, or through commercial software that we can purchase that will “pair up” with the systems we are using.

With expander use comes great responsibility.  While expanders will save many, many keystrokes (and sometimes full paragraphs of text), there can be some drawbacks to their use.  Probably the most obvious is the increased chance of inserting incorrect text.  Your doctor asks you to keep a diary for your headaches, not a diarrhea.   The patient’s name is Bob, not bowel or bladder.  The expander software I’m using right now tells me that my entry of AAA can be either abdominal aortic aneurysm, after adequate anesthesia, or awake and alert; if I’m not paying attention, the awake and alert patient could have some more pressing problems at hand.

Clearly, in addition to being responsible in our expander usage, proofreading the reports is just as important regardless of whether or not we use expanders.

Another drawback to using expanders is the potential of dampening our skills over time.  If we consistently use shortcuts, we may not immediately recall how to spell hydrochlorothiazide, uvulopalatopharyngoplasty, and gentamicin.  Should the patient be seen for a follow up visit or a followup visit?  It may be worthwhile to turn off the expanders from time to time; this will likely pay off in the long run.

What has been the most important tool or practice for you in increasing your productivity and maintaining accuracy?