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Medical transcriptionists understand that the medical record is a legal document, and handling such sensitive information requires the utmost of professional ethics and confidentiality. Because of the confidential relationship between the physician and the patient, each medical record must remain absolutely confidential.

As a working MT you should never relay patient information to outside parties. It is very important to take the security of the patient record seriously. This means that even if you are transcribing your best friend’s reports, the fact that you do so should never be discussed.

Most facilities and MTSOs (medical transcription service owners) require the transcriptionist to sign a confidentiality statement upon hiring, and violation of this is cause for termination and possibly legal recourse. Make it a practice to transcribe your reports, proof and edit them, and then forget about them. Most confidentiality has been broken because transcriptionists talk to their friends about an unusual problem she has encountered in a medical record. The problems that could occur with this are:

A. Somebody could overhear you, and that somebody could be a relative of the patient.

B. Your friend could know the patient in question and spread the news even further.

C. You portray a less than professional image when discussing contents of medical reports.

(Of course this does not include asking transcription-related questions.)

Ownership of the healthcare record belongs to the facility, but the patient is entitled to copies when a written request has been issued. Unless it is your job specifically, the medical transcriptionist should never make copies for the patient when requested directly by the patient or a family member. Remember, your job is to keep the records confidential at all times.

There are new guidelines concerning medical records in a set of laws called HIPAA (Health Insurance Portability and Accountability Act.) Parts of the HIPAA laws discuss the handling of medical records, and this could affect MTs that work at home. MTs who work at home are being encouraged to take measures to protect any information on their computers or on floppy disks. Some of these measures include password protecting your computer, keeping your virus definitions up to date, and locking any floppy disks that may contain confidential information in a file cabinet or box. It’s also important not to let anyone have access to the part of your computer that contains vital patient information and diagnoses. One transcriptionist I know was haphazard about doing so, and her husband’s boss’s medical reports were discussed. This type of thing is in direct violation of HIPAA Federal laws and could have serious consequences. Therefore, always protect your information on your computer (and shred any trash with patient names) once you begin working on the job.

Many MT services are now using “encryption” to send/receive medical records through e-mail. Encryption is a process that uses special encryption software to protect the electronic transfer of medical records. One of the more popular types of encryption programs is Cryptext which is inexpensive and very easy to use. We will explore this software and more later in the course.

Electronic signatures are popular methods of signing medical reports by the dictating physicians. This means that the physician’s typed name on the report is sufficient instead of a physical signature. Electronic signatures, however, open the door for errors that would not be caught because the physician is not reading or signing the reports. Because of this, it is vitally important that the medical transcriptionist have a complete understanding of the dictation they are transcribing in order to ensure they are transcribing exactly as the doctor dictates. That’s just another reason why a good MT course is important to your career!