• Monika A Johansen, Åse-Merete Pedersen, and Gunnar Ellingsen.
• Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway.
• Stud Health Technol Inform. 2015 Jan 1; 218: 114-119.

AbstractThis study aimed to investigate the quality-assurance work conducted by medical transcriptionists in the production of medical records, and the implications of these findings when designing a structured electronic patient record (EPR) system in which physicians are supposed to write documentation themselves. Both qualitative and quantitative methods were applied. Qualitative data were collected through informal discussions and focus-group interviews. Quantitative data were collected through the medical transcriptionists' daily recordings of their quality-assurance work. The results show the many essential quality-assurance tasks conducted by medical transcriptionists and the extent of this work. Each medical transcriptionist performs an average of more than six corrections per day, and approximately one of three dictations are corrected. We suggest that these correction and quality-assurance tasks need to be compensated for when designing and developing new structured EPRs. Some quality-assurance tasks may also advantageously be performed by secretaries in the future.

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