In the healthcare industry there is a growing need and standard for healthcare professionals to maintain complete documentation of every interaction with patients. Not only does this protect the patient as well as the medical staff involved but it also ensures a certain minimum level of care and continuity in that care. Therefore, all conversations that take place between medical staff and patients as well as audio journals (dictation) regarding patient records must be handled and documented appropriately for future reference. Because of this, there is an ever growing need for professional transcription services that offer the smooth handling of personal/medical records.

There is a great deal of confidentiality involved in the medical system when it comes to handling patient records. Those transcription companies that perform medical transcription are required to meet the minimum standard of HIPAA compliance.

For the sake of confidentiality on behalf of the patient, only those individuals who are directly involved with the care of the patient should have access to the patient records. This pertains specifically to:

• Direct care staff (RN's, LPN's, Physicians & surgical staff, etc)

• Clerical staff (Billing, admitting)

• Support staff (imaging technicians, lab workers, social workers, etc)

In some situations, outside groups or agencies may have patient information released to them - usually for legal purposes (law enforcement, attorneys, etc).

The nature of HIPAA has worked well for a number of years in protecting the confidentiality of patients and the staff that work with those patients. Unfortunately due to the nature of dictation (staff can't always write everything down) transcription services must be brought in as well. As such, those transcription companies must also strive to maintain confidentiality of patient records.

Keep in mind that legal professionals will also have to access patient records for purposes of civil and criminal law as previously mentioned. A transcription agency still has to maintain confidentiality and practice HIPAA compliance even if that transcription agency does not offer medical transcription. They may still come across those records while providing transcription to an attorney, or for a trial or criminal hearing.

Even in situations where medical records are not present, HIPAA still sets a standard for how records should be handled in terms of confidentiality. Other professionals could benefit from remaining HIPAA compliant while handling any aspect of client information for transcription purposes. This is especially true for data stemming from legal/law enforcement transcription where confidential information needs to be secured for the purpose of protecting victims and criminal rights as well as sensitive trial information.

There are numerous ways in which a transcription company ensures confidentially and protect the businesses and organizations they work with, their extended client network and of course themselves - whether working with medical records or any other confidential client info.

Controlling the Format of Records

Converting from tape-based formats to electronic formats is one of the best ways to protect data. Hard copies of patient and client information can be lost, misplaced and even stolen or damaged. Legal and professional staff is discouraged from using hard copies to make audio recordings and are instead directed to use digital formats. These files can be easily transferred to a transcription service and can be encrypted to protect the client data.

Controlling Access

Password protection has long been used to protect sensitive material and access to certain areas. It's still an effective method used by transcription services, whether a company uses an in-house transcription group or an outsourced transcription agency.

Maintaining Standards

As HIPAA standards change, it's important for those involved in client and patient care to stay current. Modern professional transcription services often attend regular training, meetings and seminars to cover the ongoing updates surrounding HIPAA compliance.

If an agency or organization is dealing with anything that is deemed sensitive or confidential client data - especially in regards to medical records - it's vital to work with a supporting transcription service that maintains HIPAA compliance and best practices through their daily routines.