Wednesday, July 11, 2007

Not the Ordinary

What is medical transcription? Is it another call center?Graveyard shift? I don't know how to speak English. It's not for me, I'm not a graduate of a medical course.

There were a lot of questions and assumptions came in our minds when Davao first heard of medical transcription. Let us first define what is medical transcription. According to Wikipedia, medical transcription is the process of converting a recorded dictation of a physician into a word document.

Medical Transcription Process (source:

When the patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past history and/or problems. The doctor performs a physical examination and may request various laboratory or diagnostic studies; will make a diagnosis or differential diagnoses, then decides on a plan of treatment for the patient, which is discussed and explained to the patient, with instructions provided. After the patient leaves the office, the doctor uses a voice-recording device to record the information about the patient encounter. This information may be recorded into a hand-held cassette recorder or into a regular telephone, dialed into a central server located in the hospital or transcription service office, which will 'hold' the report for the Transcriptionist. This report is then accessed by a Medical Transcriptionist, received as a voice file or cassette recording, who then listens to the dictation and transcribes it into the required format for the medical record, and of which this medical record is considered a legal document. The next time the patient visits the doctor, the doctor will call for the medical record or the patient's entire chart, which will contain all reports from previous encounters. The doctor can on occasion refill the patient's medications after seeing only the medical record, although doctors prefer to not refill prescriptions without seeing the patient to establish if anything has changed.

It is very important to have a properly formatted, edited, and reviewed medical transcription document. If a Medical Transcriptionist accidentally typed a wrong medication or the wrong diagnosis, the patient could be at risk if the Doctor (or his designee) did not review the document for accuracy. Both the Doctor and the Medical Transcriptionist play an important role to make sure the transcribed dictation is correct and accurate. The Doctor should speak slowly and concisely, especially when dictating medications or details of diseases and conditions, and the medical transcriptionist must possess hearing acuity, medical knowledge, and good reading comprehension in addition to checking references when in doubt.

Some Doctors, however, do not review their transcribed reports for accuracy, and the computer attaches an electronic signature with the disclaimer that a report is "dictated but not read". This electronic signature is readily acceptable in a legal sense. The Transcriptionist is bound to transcribe verbatim (exactly what is said) and make no changes, but has the option to flag any report inconsistencies. On some occasions, the doctors do not speak clearly, or voice files are garbled. Some doctors are, unfortunately, time-challenged and need to dictate their reports quickly (as in ER Reports). In addition, there are many regional or national accents and (mis)pronunciations of words the MT must contend with. It is imperative and a large part of the job of the Transcriptionist to look up the correct spelling of complex medical terms, medications, obvious dosage or dictation errors, and when in doubt should "flag" a report. A "flag" on a report requires the dictator (or his designee) to fill in a blank on a finished report, which has been returned to him, before it is considered complete. Transcriptionists are never, ever permitted to guess, or 'just put in anything' in a report transcription. Furthermore, medicine is constantly changing. New equipment, new medical devices, and new medications come on the market on a daily basis, and the Medical Transcriptionist needs to be creative and (at times) to tenaciously research (quickly) to find these new words. An MT needs to have access to, or keep on hand, an up-to-date library to quickly facilitate the insertion of a correctly spelled device, procedure, or medication dictated.

Medical transcription does not require one to be a graduate of medicine or medical related courses. To be able to master medical terminologies and other terms, training schools should be equipped to teach aspiring medical transcriptionist (MT) to be competent enough for a US based job. Although the work is being outsourced to the Philippines, it has recently attracted increased amounts of MT outsourcing from the United States. Due to high literacy in the English language (spoken as a second language and also used in business, education, and government), the Philippines is trying to position itself to become a world leader in this field. Historic connections with the US ensure that the average Filipino is perhaps capable of understanding idioms and slang used in Colloquialism, making them one of the few people outside the US to possibly be able to transcribe accurately.

If in call centers, you simply pick up a call and answer concerns of some client, in medical transcription, we simply commit ourselves to high quality transcription which means we can edit, proofread and listen to the recorded dictation again and again if you need clarifications.

A medical transcriptionist is constantly challenged to learn in an exciting occupation with interesting, ever-changing subject matter. There are always new medications and new procedures, previously unstudied specialties to learn, and new doctor-specific phraseology, accents, slangs and English as a Second Language (ESL) to master.

Medical transcription encompasses the MT, performing document typing and formatting functions according to an established criteria or format, transcribing the spoken word of the patient's care information into a written, easily readable form. Being an MT it requires correct spelling of all terms and words, (occasionally) correcting medical terminology or dictation errors. MTs also edit the transcribed documents, print or return the completed documents in a timely fashion. All transcription reports must comply with medico-legal concerns, policies and procedures, and laws under patient confidentiality.

An MT job is not the ordinary job. You work like a doctor, even if you are not actually giving any contact with the patient. You just need to make the transcription accurately or else the patient will die. It is not ordinary because it does not require age to do the job, it does not require a college diploma to do the job.

Be a medical transcriptionist.

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