Overview
A medical transcriptionist listens to a voice recording made by a doctor or other healthcare professional and translates the information into a captured electronic record. MTs produce reports that become part of the medical record, including medical histories, discharge summaries, physical examination reports, operating room reports, diagnostic imaging studies, consultation reports, autopsy reports, referral letters and other documents.
These reports are important because they serve as foundation for ongoing clinical decision-making, continuity of care, maximized reimbursement, and risk management.
Transcribing medical reports is highly detailed work that requires patience, focus, and attention to detail. The transcriptionist needs extensive knowledge of medical terminology, anatomy and physiology, medical procedures, pharmacology and other medical terms. MTs apply advanced clinical knowledge to the art of accurately interpreting and capturing patient care encounters, a skill set that must be applied in the challenging setting of enabling technologies, an expansive and constantly evolving medical language, and an often unpredictable array of practitioners who dictate in haste or speak English as a second language.
Transcriptionists don’t just record the exact words the doctor says. They turn phrases and notes into complete, grammatically correct sentences. They format information according to guidelines for medical records. And they often find and question inconsistencies and inaccuracies in the doctor’s verbal report. Doctors come to rely on their transcriptionists to help ensure the accuracy and completeness of their medical reports.
Some transcriptionists use voice recognition software to aid in the initial oral-to-written transcription. However, these drafts must be carefully proofed against the original recording to ensure accuracy. Further editing is always required to produce a comprehensive and accurate report.
Transcriptionists also keep reference materials close at hand, whether in print form or online. They frequently consult medical dictionaries, procedural guides, coding manuals, diagnostic guides and style manuals.
Accuracy is critical. Once the transcriptionist prepares a first draft of the report, the doctor reviews and edits the copy to clarify and correct the information. The transcriptionist then revises the report, incorporating the doctor’s changes. This process may be repeated to ensure that the final report is as clear and complete as possible.
Because medical records are confidential, transcriptionists cannot discuss the content of the reports they prepare, and they must be careful to keep all recordings, paper and electronic files secure. Today, most files are sent online, making security, backup storage, and virus protection a paramount concern.
Compensation models can vary from an hourly rate to a per-unit incentive model to some combination of both, with some kind of incentive program being the most common scenario you will encounter.
Job growth is solid, because the healthcare industry is growing. As the baby boomer generation moves into the long-term healthcare spectrum (creating greater patient volume in the US healthcare system) and boomer MTs retire from practice, industry experts predict a critical shortage of documentation workers to meet the evolving demands of healthcare.
While Speech Recognition Technology (SRT) is rapidly changing the role of the medical transcriptionist, this automating technology is being used primarily in healthcare as a productivity-enhancement tool for MTs, medical transcription services, and healthcare facilities which has created a new hybrid role for traditional MTs – speech recognition editor. Most industry experts agree integrating SRT with an informed knowledge worker will continue to be the best documentation solution for healthcare.
Another factor driving growth for this career is the movement towards digitizing all medical records. President Obama has promised funding toward establishing electronic medical records for all patients, which would involve transcribing all paper-based charts into electronic files.
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Medical Transcriptionist 14 Sep 2009 [pdf, 207 KB]