AT3: Transcription Médicale et Coordination

AT3 Revision Notes

• AT3 covers processing patient/user records and coordinating related operations.

Chapter 1: Transcribing Medical Information

• Includes course overview
• Covers medical records
• Focuses on transcription of information
• Highlights quality review and regulatory procedures
• Discusses continuity of care.

How to Train for Document Processing and Patient Care Coordination

• SAMS plays a role in managing and tracking patient records.
• Medical transcription involves rewriting text from conversations between doctors and patients.
• SAMS is responsible for recording medical information.
• Accurate and timely transcription is essential for proper patient care.
• Transcription accuracy is critical to good patient care.

Medical Vocabulary

• Medical transcription requires specialized vocabulary, with precise spelling, and an understanding of medical terms and their origins.
• Knowing prefixes and suffixes is necessary to understand medical vocabulary.
• Examples of medical terms include: Hyperglycaemia, Hypoglycaemia, Supraclavicular, Subclavicular, Apnea and Dyspnea.

Patient Records

• Essential patient information is required and should be recorded correctly in the patient record.
• Details on the patient include: full name (with ID), sex, date of birth, address, phone number, email, profession, treating physician, medical insurance, and any contacts (e.g., person of confidence/guardian).
• Additional details (like medical history, medications, family history, risk factors) might be added later.

Administrative Management Methods

• SAMS uses software to manage administrative tasks like creating and updating records, tracking appointments, ensuring information is accessible during patient care, and for audit purposes.
• Using a structured system for storage of information is recommended.
• The program PMSI is essential for gathering and documenting medical information for statistical analysis within the healthcare system.

Medical Record Tools and Software

• HelloDoc software allows patients to schedule appointments online, record information for their medical records, and interact with administrative staff.
• DoctolibPro functions similarly, allowing seamless data transfer between different actors of the healthcare system.
• DrSanté provides the same functions as the others, in a format suitable for both desktop computers and mobile devices.
• Recording, storing, retrieving, and updating patient files is crucial for medical practice.

Medical Records: General Information

• The medical record is a critical document in healthcare, containing information necessary for patient care and treatment.
• Medical records contain patient demographics, medical history, diagnoses, treatments, and follow-up information.
• Accurate, complete, and up-to-date records support medical decisions, ensure continuity of care, and facilitate efficient patient care.

Medical Record: Patient Information

• Patient information in medical records is crucial.
• Patient records should include details like name, date of birth, address, contact information, and medical history.
• The record should also include details regarding treatment plans, test results, prescriptions, follow-up appointments, and other relevant information

Medical Records: Information for the User

• Patient records include information on the patient's care, like tests, medications, and appointments, ensuring continuity.
• These records provide important details for patient management and tracking.

Medical Record: Confidentiality and Storage

• Medical records hold sensitive information, therefore safety and security of the documents are very important
• Policies and procedures regarding data access should be clearly defined, limiting access to authorized individuals.
• Data should be secured and kept confidential during storage.
• Storage duration varies depending on circumstances (like the type of medical facility or the specific needs of the patient).

Transmission of Information

• Effective communication within a medical team is fundamental.
• Various methods (e.g., letters, emails, shared platforms) streamline information exchange.
• A well-organized system prevents information loss or misunderstanding.

Medical Records: Storage, Maintenance

• Medical records should be stored securely, to maintain patient confidentiality.
• Access to the records should be restricted to authorized personnel.
• Regular maintenance to ensure records are up-to-date and accurate.

Confidentiality

• Confidentiality is vital in the handling of sensitive patient information, with clear policies and procedures governing access, transmission, and storage of data, to ensure patient privacy.

Medical Records: Legal Aspects

• Laws and regulations govern medical record confidentiality and storage.

Medical Records and the Patient

• Patient participation in their record management is crucial.
• Clear communication and accessibility of information are vital.
• Patient rights in terms of information access, rights to correction and erasure should be respected.

The use of Digital Tools for Medical Records

• The digitalization of medical records is becoming more common and the use of digital tools for access, storage, analysis or transmission brings various advantages: speed, accuracy and sharing possibilities.
• Using digital tools means the adoption of a protocol and procedures suited to electronic processing and transmission.
• The confidentiality of information must be absolute to maintain trust in the system and procedures.

Medical Records: Patient Update

• Keeping patient records updated with current information is necessary for proper care.
• It's important to collect, record, and update information on a regular basis, ensuring accuracy and consistency.

Medical Records and Associated Entities

• Key information relevant to the patient's healthcare, including medical history, diagnoses, treatments, and any follow-up appointments.
• It's essential to have a clear procedure in place for incorporating data related to the patient's health, including demographics, medical history, or any treatment plan.