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Health Care Documentation Specialist

Overview

A health care documentation specialist, sometimes known as a medical transcriptionist or a medical documentation editor, listens to a voice recording made by a doctor or other health care professional and either transcribes the information into a captured electronic record, or reviews and edits a version produced by a speech recognition technology software program for the record. The reports produced become part of the legal medical record, and include 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.  

Editing or transcribing medical reports is highly detailed work that requires patience, focus and attention to detail.  Health care documentation specialists need extensive knowledge of medical terminology, anatomy and physiology, medical procedures, pharmacology and other medical terms. They 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.

Health care documentation specialists often don’t just record the exact words the doctor says. They may be responsible for turning 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 have come to rely on these specialists to help ensure the accuracy and completeness of their medical reports.

Some health care providers and facilities 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 and editors 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. In some cases, the first draft of a report is reviewed by health care provider, edited and returned for another draft incorporating the doctor’s changes. In other instances, an editor or transcriptionist may flag a report for verification of accuracy and review by someone in a quality assurance position before it goes to the author for signature. In many instances, the transcriptionist is expected to produce the first time a document ready for final signature.

Because medical records are confidential, transcriptionists cannot discuss the content of the reports they prepare; they must be careful to keep all recordings, paper and electronic files secure and be prepared to follow federal guidelines for confidentiality, security and privacy. 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 encountered.

Job growth is solid, because the health care industry is growing. As the Baby Boomer generation moves into the long-term health care spectrum (creating greater patient volume in the U.S. health care system) and transcriptionists from that generation retire, industry experts predict a critical shortage of documentation workers to meet the evolving demands of health care.

While speech recognition technology is rapidly changing the role of the traditional medical transcriptionist, this automating technology is being used primarily in health care as a productivity enhancement tool for transcriptionists, medical transcription services and health care facilities that have created a new hybrid role for traditional medical transcriptions – speech recognition editor. Most industry experts agree integrating the technology with an informed knowledge worker will continue to be the best documentation solution for health care.

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 or utilizing electronic scanning. 

According to the Bureaou of Labor Statistics, the median annual wage of medical transcriptionists was $32,900 in May 2010. The median annual wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $21,960, and the top 10 percent earned more than $46,220. 

Working Conditions

Many health care documentation specialists work as independent contractors or full- or part-time employees, often working in their own homes. Others are employed in medical offices or hospitals and may spend part of their time performing office duties in addition to documentation.

They work with every type of health care provider, including doctors, nurses, physical therapists, dietitians, and other health workers.

Transcriptionists and editors spend the majority of their time sitting in front of a computer screen and use a headset to listen to their computer or another device that plays back digital voice recordings. A key command or foot pedal may be used to pause and restart the recording as the transcriptionist keys the words into an electronic file or edits the already-recorded document.

Documentation specialists are at risk of work-related injury, including repetitive motion injuries, eye strain, neck and back pain and other problems related to the nature of their work. There can be pressure to produce reports quickly, as well, along with stress associated with ensuring that every report is complete and accurate.

Transcriptionists who work in an office typically put in a standard 40-hour week. Self-employed workers may choose to work longer hours, including evenings and weekends, to increase their income, meet deadlines and balance work and family responsibilities.

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Note: The Association for Healthcare Documentation Integrity reviewed this career profile.

Academic Requirements

Health care documentation specialists need to be able to type accurately and quickly but the even greater challenge for this career is mastering complex medical terminology and critical thinking skills to determine the accuracy of the reports and follow established protocols to deal with inaccuracies.

To be able to identify, spell and use the appropriate expanded form of thousands of medical terms, medications, acronyms, abbreviations, and codes, students in this field study medical language, anatomy and physiology, disease processes, laboratory terminology, medical procedures, instruments, equipment, pharmacology and other words frequently used in medical reports. They build a library of reference books and online databases, which they use frequently throughout their career. They also must have a command of English grammar, spelling, and punctuation. Computer and Internet skills are important, as well.

Training is available at many community colleges, vocational schools, and online education programs. Candidates seeking a credible education in health care documentation should select a program that has met the industry benchmarks for such training. The Association for Healthcare Documentation Integrity and the American Health Information Management Association provide oversight and approval of industry training programs in health care documentation and medical coding. The Association for Healthcare Documentation Integrity maintains a list of approved schools.

Schools and technical programs that have met the standards for approval offer training programs of typically 10 months to two years in length. Graduates from approved schools are generally better prepared to sit for the registered medical transcriptionist credential, a benchmark that demonstrates job readiness to industry employers.

Two or more years of acute care documentation experience further qualifies the specialist to take the exam for certified medical transcriptionist credentialing.