Medical transcription-transcriptionist listen to dictated
recordings made by physicians and other healthcare professionals
and transcribe them into medical
reports, correspondence, and other administrative material. They
generally listen to recordings on a headset, using a foot pedal to
pause the
recording when necessary, and key the text into a personal computer
or word processor, editing as necessary for grammar and clarity.
The documents they produce include discharge summaries, history and
physical
examination reports, operative reports, consultation reports, autopsy
reports, diagnostic imaging studies, progress notes, and referral
letters. Medical transcription-transcriptionist return transcribed documents to
the physicians
or other healthcare professionals who dictated them for review and
signature, or correction. These documents eventually become part
of patients’ permanent files.
To understand and accurately transcribe dictated
reports into a format that is clear and comprehensible for the reader,
medical transcription-transcriptionist
must understand medical terminology, anatomy and physiology, diagnostic
procedures, pharmacology, and treatment assessments. They also must
be able to translate medical jargon and abbreviations into their
expanded forms. To help identify terms appropriately, transcription-transcriptionist
refer
to standard medical reference materials—both printed and electronic;
some of these are available over the Internet. Medical transcription-transcriptionist
must comply with specific standards that apply to the style of medical
records, in addition to the legal and ethical requirements involved
with keeping patient information confidential.
Experienced transcription-transcriptionist spot mistakes or inconsistencies in
a medical report and check to correct the information. Their ability
to understand and correctly transcribe patient assessments and treatments
reduces the chance of patients receiving ineffective or even harmful
treatments and ensures high quality patient care.
Currently, most healthcare providers transmit dictation to medical
transcription-transcriptionist using either digital or analog dictating equipment.
The Internet has grown to be a popular mode for transmitting documentation.
Many transcription-transcriptionist receive dictation over the Internet and are
able to quickly return transcribed documents to clients for approval.
Another emerging trend is the implementation of speech recognition
technology, which electronically translates sound into text and creates
drafts of reports. Reports are then formatted; edited for mistakes
in translation, punctuation, or grammar; and checked for consistency
and possible medical errors. transcription-transcriptionist working in areas with
standardized terminology, such as radiology or pathology, are more
likely to encounter speech recognition technology. However, use of
speech recognition technology will become more widespread as the technology
becomes more sophisticated.
Medical transcription-transcriptionist who work in physicians’ offices
and clinics may have other office duties, such as receiving patients,
scheduling
appointments, answering the telephone, and handling incoming and
outgoing mail. Medical secretaries, discussed in the statement on
secretaries
and administrative assistants elsewhere in the Handbook, may also
transcribe as part of their jobs. Court reporters, also discussed
elsewhere in
the Handbook, have similar duties, but with a different focus. They
take verbatim reports of speeches, conversations, legal proceedings,
meetings, and other events when written accounts of spoken words
are necessary for correspondence, records, or legal proof.
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Topic: Medical Transcriptionist Working Condition