HIPAA hints for dictators

HIPAA requires that we educate our staff on the rules and how they apply to their jobs. I have written about this topic in the past and fortunately, most facilities already have training programs in place. While this basic training is being provided, there is so much more that we can do to make the system work better.

NEMT President Linda Allard

Our staff needs to understand ways that they can both help us follow the HIPAA guidelines and assist with patient safety. Education and explanations will go a long way toward helping everyone live a HIPAA lifestyle. Let’s use dictation practices as an example.

It used to be (I’m showing my age) that dictators picked up a tape recorder and dictated their patient’s name and maybe a medical record number and then the report. The transcriptionist listened to the tape, typed it up, and printed it. The finished report was then placed in the patient’s paper chart.

Now, in most cases, the dictator is required to use a telephone to access some sort of dictation system where he or she punches in demographic information about the patient and then dictates the report. Once the dictation is complete, the report is transcribed and, in some manner, it is returned to the patient’s electronic chart. What most people don’t realize is the importance of the numbers the dictator punches in. These numbers pull up specific information about the patient and the associated visit. This data is then used to ensure that the final document is returned to the correct patient’s chart, so accuracy is critical.

How does this relate to HIPAA and education? We need to explain all of this to our dictators. If you don’t know how important something is and why we are asking for all this information, it is easier not to do it. I have found that once I explain the system and what all of the required data does, they feel much better about providing it.

We also need to educate our dictators on the fact that they should verbally provide the patient’s name and also identify themselves. There are some partial dictations that don’t require this step, but if they are doing a regular report, how will the transcriptionist know if the data brought up is the right patient if the name isn’t said? It is very easy for a dictator to hit the wrong button and not realize it, and as transcriptionists we want to verify the accuracy of the information punched in for you. As professionals, we perform this verification step to ensure each document is routed to the correct patient’s record and signed by the appropriate healthcare provider.

Providing a detailed explanation of why things are done the way they are to both your staff and dictators will help them remember the steps and feel better about performing them.

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About Linda Allard

Linda Allard is the president of NEMT.
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