Healthcare Informatics: “Guidelines Will Standardize Dictated Documents” by Brian Albright

“Dictated medical notes and other types of transcribed patient records are usually available in electronic form, but have traditionally not been very useful in the context of an electronic medical record (EMR) system. Transcribed records follow a variety of formats depending on the clinical setting and type of transcription service used, making them difficult to search.”

“There’s no real structure to the narrative that’s being inserted into the EMR,” says Jay Cannon, president of the Medical Transcription Industry Association (MTIA), Chicago. “The information is visibly accessible, but within the system it’s just a text blob.”

Now, a new standard based on the Health Level Seven (HL7) Clinical Document Architecture (CDA), could help improve the utilization of these types of documents.