Medical transcription

Summary

Medical transcription, also known as MT, is an allied health profession which deals in the process of transcribing or converting recorded dictations by physicians and/or other healthcare professionals regarding patient medical record to a written text. This written text may be stored as printed and/or electronic data. The electronic storage of medical records are the preferred means of most medical professionals in order to document patient care and facilitate healthcare delivery regardless of geographical distance. Medical transcription establishes document format, data entry, corrects spelling and medical terminology errors, transcribe/edit documents, and complies with medical-legal policies and procedures.

The medical transcription is also used as the name of the document (electronic or physical) that results from the medical transcription process, normally in reference to a healthcare professional's record of the medical encounter with a patient. It is referred to by some as a "medical record." A transcribed record can also be merged into a larger document, again called a medical record, which contains additional information from the patient encounter.

Current forms of medical transcription involve digital voice files and speech recognition. Today, medical transcription is the primary mechanism a physician communicates with another physician about the state and treatment of a patient. In more recent time, it is required to be used as justification for a medical bill or application for worker's compensation benefits.

As a profession

File:Medical transcriptionist.jpg

a medical transcriptionist working in a medical transcription environment

An individual who performs medical transcription is known as a medical transcriptionist, or less frequently and incorrectly, a medical transcriber. A medical transcriptionist is the one responsible for documenting patient medical records. The term medical transcriber may also refer to an electronic equipment used to perform medical transcription.

There are no formal educational requirements for MTs. Education in medical transcription may be obtained through traditional schooling, certificate or diploma programs, distance learning, and/or on-the-job training. But some countries require 18 months to 2 years of specialized MT training. An MT profession requires mastery in medical terminology, adroitness in editing, and the ability to type while listening.

Medical transcription does not require registration or certification. However, some do seek registration or certification for personal or professional reasons. It is important to note that obtaining a certificate from a medical transcription training program does not entitle an MT to use the title of Certified Medical Transcriptionist (CMT). The CMT credential is only earned by passing a certification examination conducted by The American Association for Medical Transcription (AAMT). The AAMT also offers the credential of Registered Medical Transcriptionist (RMT). According to the AAMT, the RMT is a lower-level credential than the CMT.

As of March 7, 2006, MT occupation became an eligible U.S. Department of Labor apprenticeship, which is a two-year program focusing on acute care facility (hospital) work.

Job Requirements

High school diploma or GED with 1 to 3 years experience directly related to the duties and responsibilities specified.

Knowledge, Skills and Abilities Required

Knowledge of medical terminology
Transcription skills.
Ability to sort, check, count, and verify numbers.
Skill in the use of operating basic office equipment.
Ability to follow routine verbal and written instructions.
Ability to document work in progress.
Records maintenance skills.

MT Duties and Responsibilities

Transcribes and edits recorded or written material, including operative reports, discharge summaries, patient history and examinations, physician letters and notes, and pharmacy, rehabilitation, autopsy, and x-ray reports.
Verifies accuracy of patient information such as name and identification number; verifies accuracy of transcription for correct punctuation, grammar, and spelling.
Maintains logs of medical procedures, incoming dictation, and transcription records.
Sorts, copies, prepare, assemble, and files records and charts.
Distributes and collects dictation and transcribed reports; follows up on physicians' missing and/or late dictation.
Performs quality assurance documentation.
May maintain disk and disk back up system; may order supplies and report equipment operational problems.
May collect, tabulate, and generate reports on statistical data, as appropriate.
May assist with telephone coverage.
May take minutes of transcription department meetings.
Performs miscellaneous job-related duties as assigned.

Distinguishing Characteristics

Position requires: a) Transcription, verification, and editing of various recorded and/or manuscripted medical reports, documents, and correspondence. b) Maintenance of multiple logs and records. c) Sorting, filing, copying, and preparation of files, records, and charts. d) Collection and distribution of dictation, to include followup of missing and/or late dictation. e) Quality assurance of dictation output.

Medical transcription process

When a patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past problems. The doctor may do a physical examination, conduct various laboratory or diagnostic studies, make a diagnosis, and then decides on a plan of treatment and discusses it with the patient. After the patient leaves, the doctor uses a voice recording device to record the information about the interaction with the patient. This information is then sent to a medical transcriptionist and received as a voice file, who then listens to the voice file and transcribes it into the required format to make a medical record which is also a legal document that may be subpoenaed. The next time the patient visits the doctor, the doctor can call for the medical record. The doctor may also refill medications after seeing only the medical record.

It is important to have a properly written, edited and reviewed medical transcription document. If a medical transcriptionist accidentally typed a wrong medication or wrong diagnosis, the patient's life will be put at risk if the doctor will not review the document for its consistency. 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 diseases, and the medical trasncriptionist must possess a hearing acuity, medical knowledge, and a good reading comprehension.

Outsourcing of Medical Transcription

Due to the increasing demand to document medical records, other countries started to outsource the services of a medical transcriptionist. In the United States, medical transcription business is estimated to worth US $10 to $25 billion annually and growing 15 percent each year^{[citation needed]}. The main reason for outsourcing is stated to be the cost advantage because of cheap labor in developing countries, their currency rates as compared to U.S. dollar.

It is a really big controversy on whether work should be outsourced, mainly due to three reasons^{[citation needed]}: 1) The unemployment in the country from where the work is being outsourced. 2) The concern about privacy of patients as the work is going from the country where the patient is located to a country where the law about privacy may not even exist. Some of the countries that outsource transcription work are United States, Britain, and Australia. 3) The quality of work. Many foreign-born transcriptionists simply do not have the requisite education to do the job with reasonable accuracy. Many of those who speak English do not know American expressions and slang, which doctors often use. These transcriptionists often work for a fraction of what transcriptionists are paid in the United States.

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