Why is it important to document the Medical Transcripts?

The medical transcripts can be converted into a hard copy and filed with the patient records or can be stored in the electronic format. The transcriptionists can be an in-house employee or an outsourced professional. Through Medical Transcription services, the physicians have succeeded in reducing their documentation burden.

A transcriptionist listens to the recorded dictations made by the physicians and enters the message into written format. They also interpret abbreviations and medical jargons and prepare patient history, diagnosis report and other relevant documents. They either work under a physician or for an outsourcing company.  Nowadays more people tend to work from home as a medical transcriptionist whereby they receive the recordings and submit the medical transcripts electronically. A typical transcriptionist should possess postsecondary training and have an understanding of English grammar and should know to handle the transcription software. Many vocational schools and community colleges provide this training. They even run a certificate program and the syllabus includes medical terminology, anatomical studies, English grammar, punctuation and documentation training. Some students also receive on the job training.

The basic skills a medical transcriptionist should possess are good grammar knowledge, computer and software proficiency, healthy hearing acuity and ability to listen to long dictations. As a career advancement medical transcriptionists can be elevated as supervisors, trainers, editors or consultants.  Those with higher training can even become medical technicians or medical information administrators.

A normal function of a transcriptionist consists of the following routine:

-          Receive the recordings of the dictations made by the physicians mostly via internet.

-          Listen carefully to the dictations using their headsets.

-          Key in the text into their computers

-          Produce documents concerning the patient’s health ailment like progress notes, medicines administered, diagnosis reports, discharge summary and surgical reports.

-          Edit the documents for grammar and mistakes.

-          Compare the recording with the final draft to check for inconsistencies and to rectify them.

-          Sometimes use transcription software (which uses the voice recognition technology to convert the dictations into text) and then edit it for corrections.

-          Send back the medical transcripts back to the health care professionals and receive their feedback.

There are certification courses available for Medical transcription. They are not mandatory but will give an indication of the competency level. American Association of Medical Transcription is one such body which awards voluntary certifications. The career prospects for medical transcriptionists are on the increase and are expected to accelerate faster than any other profession.  There are two reasons for this. One is the increasing number of aging patients who require well documented medical history for further treatments. The second is the growing awareness about the advantages of maintaining proper medical documents. With medicines constantly changing and new medications and medical equipments flooding the market daily, medical Transcriptionists have to be a quick learner and keep updating themselves to provide accurate and error free medical transcripts.