What Is Medical
Transcription? Submitted By: Greg Heslin In recent years the medical
field has been going to great lengths to provide ways for doctors to
spend more quality time with their patients and less time doing paperwork
and updating files. To hone in on this problem the medical transcription
profession was created.
Medical transcriptionists, MTs, originally served as secretaries to
medical professionals who dictated detailed patient information. The
MTs in turn spent hours retyping the dictation on typewriters in order
to document it in the patients’ permanent files. Over the years,
however, there has been an abundance of modern technology created to
make the MT’s job easier and more accurate. Typewriters have been
replaced with high-tech analog recorders and phone diction systems that
allow medical professionals to dictate
what they want included in the records.
According to the U.S. Department of Labor, doctors can dictate patient
histories, operation reports, autopsy reports, progress notes, referral
letters, and other documents for MTs to transcribe. After the dictation
process is complete, the medical transcriptionists listen to the information
and write everything in a clear and grammatically correct fashion, making
the files easier to read and understand. The MTs then send the document
back to the professional who dictated it to review and revise the document
before signing off for its completion. After this process is complete,
the final revised copy will become part of the patient’s permanent
record.If the process is done correctly the files will be more easily
accessible and accurate and will, in turn, help medical offices and
hospitals run more smoothly. It is important that doctors and medical
transcriptionists establish a strong working relationship and have constant
communication for the process to be successful. The doctors must be meticulous
in their recordings, making sure to speak clearly and include every piece
of information needed for the patient’s file. If there are any errors,
not only will the physician’s and transcriptionist’s jobs
be in danger, but the patient may receive the wrong medication or diagnosis.
Unfortunately, there are many physicians who simply choose not to review
their dictations before handing them over to a transcriptionist and will
instead sign off on the recording via an electronic signature.
When this occurs, the data entry transcriptionist
must be even more meticulous in the writings and is encouraged to voice
any concerns about the original dictation. Due to the ever-present time
crunch in medical offices and hospitals, these types of errors are not
uncommon, making correct transcription that much more vital. Approximately
seven out of ten MTs work in medical offices or hospitals where they serve
as administrative assistants in addition to their MT duties. However,
there are a large number of individuals who do their transcribing from
home offices due to the ease and comfort of an at home job. Often times,
health care providers will e-mail their recordings so the MTs are able
to create files quickly. MTs are also taking advantage of advancements
in speech recognition technology, which translates a recorded voice into
written text. In these cases, the MTs sole responsibility is to revise
the documents for any grammatical mistakes and inconsistencies in diagnosis
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