Wiki Transcriptionist; meaningful use

[Jmraney]

Is there ever an instance when it would be appropriate for a transcriptionist to enter information in the EMR under their own name(i.e. HPI, physical exam, discussion/summary, etc.) if they are acting as a transcriptionist, and the doctor is not present while still meeting meaningful use?

The transcriptionist is not a credentialed medical assistant or licensed healthcare professional.

Please share some links that may help me out.

Thank you!

 

[mitchellde]

I am not sure what you mean. The transcriptionist by job description can only transcribe exactly what is dictated there can absolutely no embellishment of any kind. Look up the definition of transcriptionist and check the federal register.

 

[Jmraney]

Thank you for the help. My concern is not what a transcriptionist does rather that someone unaccredited is entering infromation directly in the EMR under their own name. I do not think this meets meaningful use.

 

[thomas7331]

You're correct that this won't meet meaningful use. The transcriptionist, by definition, would only be entering free text into the EHR and you would not be able to capture any data elements from this. The same thing would apply if the physician was using voice recognition software to dictate directly into the free text fields of the EHR. To get meaningful use, the software tools need to be use as they were designed. If the EHR is just used it as a place to house text records, it is not being used in a way that captures the necessary information.