Wednesday, October 15, 2008

What You Need to Know About Medical Transcription

About Transcription

Transcription is the conversion of a recorded voice source into a typewritten document such as the proceedings of a court hearing, corporate meeting, teleseminars, webinars, subtitling, data entry, and medical consultation. A transcriptionist is a person who performs such jobs.

About Medical Transcription

Confidential patient information is converted to a text document by a medical transcriptionist with the use of a computer. This text may be printed and hand placed in the patients’ record, archived, and/or retained only as an electronic medical record. Medical transcription can be performed in a hospital, via remote transmission to the hospital, or directly to the actual providers in off-site locations.

The report is used as the document which results from the medical transcription process, normally in reference to the healthcare professionals’ specific encounter with a patient on a specific date of service. This report is referred to by many as a "medical report". Each specific transcribed report, with its own specific date of service, is then merged and becomes part of the larger patient record commonly known as the patient's medical history.

A medical transcriptionist (MT) performs document typing and formatting functions according to an established criteria or format, transcribing the spoken word of the patient's care information into a typewritten, easily readable form. An MT is required to have knowledge of the spelling of all terms and words to be able to correct medical terminology or dictation errors. MTs also edit the transcribed documents, and 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.

About the Medical Transcription Profession

An individual who performs medical transcription is known as a medical transcriptionist or an MT, or a medical transcriber. A medical transcriptionist is the person responsible for converting the patient's medical records into typewritten format rather than handwritten, the latter more prone to misinterpretation by other healthcare providers. In the late 1990s, medical transcriptionists were also given the title of Medical Language Specialists or Health Information Management (HIM) paraprofessionals.

Working in medical transcription leads to a mastery in medical terminology and editing, the ability to listen and type simultaneously, the utilization of playback controls on a foot pedal and the use of Expresscribe to play and adjust dictations while maintaining a steady rhythm of execution.

There is a great degree of internal debate about which training program best prepares an MT for industry work. It is always advised by different medical transcription company owners or employers that a knowledgeable MT is highly valued. Always look for a training institution that gives the best value for your money. MTs who can consistently and accurately transcribe multiple document work-types such as General Transcriptions, Legal Transcriptions and Medical Transcriptions, and return reports within a reasonable turnaround-time (TAT) are sought the most. TATs (turnaround time) set by the service provider or agreed to by the transcriptionist should be reasonable but consistent with the need to return the document to the patient's record in a timely manner.

About the Medical Transcription Process

When a 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, and 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 digital recorder or a phone voice recorder, into a central server located in the hospital or transcription service office, and then the gatekeeper will distribute recorded files for the transcriptionist. This report, received as a voice file, is then accessed by a medical transcriptionist 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 transcribed files will now go into quality assurance by MT Editors and MT Proofreaders. 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.

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 a 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.

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