Medical transcription, also known as MT, is an allied health profession which encompasses the process of transcription or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals into text format.
Traditional medical transcription is a form of document creation that the medical industry considers outdated, but necessary as a means of providing the necessary documentation needed to satisfy regulatory and insurance provider requirements. The practice of Modern Medicine dictates that the physicians spend more time serving patient needs than creating documents in order to make financial ends meet. More modern methods of document creation are being implemented through the technology of computers and the internet.
Medical Transcriptionists
Voice Recognition (VR) is one of these new-age technologies. With the power to write up to 200 words per minute with 99% accuracy Voice Recognition has freed physicians from the shackles of traditional transcription services.
Pertinent, up-to-date, confidential patient information is converted to a written text document by a medical transcriptionist. This written text may be printed (and hand placed in the patient's 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 of service (doctors or their group practices) in off-site locations. Hospital facilities often prefer electronic storage of medical records due to the sheer volume of hospital patients and the accompanying paperwork. The electronic storage in their database gives immediate access to subsequent departments or providers regarding the patient's care to date, notation of previous or present medications, notification of allergies, and establishes a history on the patient to facilitate healthcare delivery regardless of geographical distance or location.
The term transcript or "report" as it is more commonly called, is used as the name of the document (electronic or physical hard copy) which results from the medical transcription process, normally in reference to the healthcare professional's specific encounter with a patient on a specific date of service. This report is referred to by many as a "medical record". Each specific transcribed record or 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.
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. MT 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.
In transcribing directly for a doctor or a group of physicians, there are specific formats and report types used, dependent on that doctor's speciality of practice, although history and physical exams or consults are mainly utilized. In most of the off-hospital sites, independent medical practices perform consultations as a second opinion, pre-surgical exams, and as IMEs (Independent Medical Examinations) for liability insurance or disability claims. Private practice family doctors rarely utilize a medical transcriptionist, preferring to keep their patient's records in a handwritten format.
Currently, a growing number of medical providers send their dictation by digital voice files, utilizing a method of transcription called speech or voice recognition. Speech recognition is still a nascent technology that loses much in translation. For dictators to utilize the software, they must first train the program to recognize their spoken words. Dictation is read into the database and the program continuously "learns" the spoken words and phrases.
Curricular requirements, skills and abilities
High school diploma or GED, plus range of 1 to 3 years' experience that is directly related to the duties and responsibilities specified, and dependent on the employer (working directly for a physician or in hospital facility).
Knowledge of medical terminology is helpful.
Average to above-average spelling, verbal communication and memory skills.
Ability to sort, check, count, and verify numbers with accuracy.
Skill in the use and operation of basic office equipment/computer; eye/hand/foot coordination.
Ability to follow verbal and written instructions.
Records maintenance skills or ability.
Good to above-average typing skills.
Basic MT knowledge, skills and abilities
Knowledge of basic to advanced medical terminology is essential.
Average to above-average verbal communication and memory skills.
Ability to sort, check, count, and verify numbers with accuracy.
Demonstrated skill in the use and operation of basic office equipment/computer.
Ability to follow verbal and written instructions.
Records maintenance skills or ability.
Average to above-average typing skills.
Knowledge and experience transcribing (from training or real report work) in the Basic Four work types.
Knowledge of and proper application of grammar.
Knowledge of and use of correct punctuation and capitalization rules.
Demonstrated MT proficiencies in multiple report types and multiple specialties.
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