Death is an unfortunate part of human existence, and unfortunately it’s all too common on a daily basis. Not only does the influx of terminally ill and mortally wounded patients continue to flow into the hospitals where staff are challenged for time, but the number of deceased patients in the system can be taxing on forensic pathologists that must perform autopsies on the body of the deceased. The time constraints placed on medical staff is one reason why medical transcription is in such high demand.
Where forensic pathologists were once required to document their findings in-house, they can now save themselves the time and cost by working with outside agencies for autopsy transcription.
The most common method for this is by way of digital recording, where the forensic pathologist maintains a recording device that operates as they perform the autopsy. As each procedure and step in the autopsy takes place there is auditory documentation (as well as video in some cases). This information is passed to outside agencies with an expertise in autopsy transcription, usually through an encrypted digital transfer.
Forensic pathologists can also utilize toll free phone-in-dictation to narrate their lab reports and findings after performing an autopsy.
The autopsy is vital to determining the cause of death in many cases, particularly those where the cause is not readily visible or easy to determine. Likewise, it’s done if there are conflicting signs that could point toward multiple causes of death or even a medical issue that can only be determined through examination of the organs.
An autopsy is performed for legal, research or medical purposes. In any situation, accuracy is necessary during the dissection and internal examination of the deceased. When it’s done for legal or medical purposes, an inaccurate determination could pose additional legal problems and affect the outcome of a legal trial or a matter of life insurance compensation for a family as an example.
Because the forensic pathologist is unable to take notes while they work, they use audio as mentioned above to dictate notes while performing the autopsy. These notes must be carefully transcribed by a professional in order to carry over the accuracy of the examiner. If the continuity of the information is not maintained, it can negatively impact legal, medical, and financial issues surrounding the deceased and those left behind.
Likewise, if the autopsy is done for research purposes, poor dictation and sloppy transcription can mar months or even years of research – wasting thousands of dollars spent on researching the effects of drugs, lifestyle choices, research work against specific diseases and more.
Because there is a transfer of patient information, there still must be a measurable amount of care taken in controlling the records and confidential data of the patient even though the patient is deceased. This means that the service handling the outsourced transcription needs to maintain HIPAA standards and practices in managing the data.
Some may question the need for confidentiality where deceased patients are concerned, however it’s not a matter of whether or not a patient is deceased. Protected Health Information must remain protected as long as the information is being maintained. It can be released for certain purposes (research, law enforcement or legal purposes, identification of the deceased, funeral arrangement) though medical records are not openly available to the public without authorized request. As such, the transcription agency handling the autopsy transcription is under obligation to maintain all the necessary HIPAA precautions in handling the information.
Forensic pathology transcription is a highly specialized field, and it’s important to work closely with transcription services that are trained and have experience working within the field of forensic pathology.