Medical Transcription

What is Medical Transcription?The process of converting voice dictation into a permanent written record utilizing word processing equipment and software.Each day in hospitals, thousands of patients are admitted and discharged. Examinations are conducted, procedures are performed and recommendations are made.

What is Medical Transcription?Each patient-related activity and procedure must be meticulously documented and then added to the patient's permanent record.

Physicians and medical record handlers alike must be extremely careful to ensure that detailed patient identification information accompanies each procedure and examination report to avert potentially disastrous mix-ups.

What is Medical Transcription?Over time, all of this information accumulates in a centralized medical records repository where it serves as a critical resource for patient care - facilitating accurate diagnoses and appropriate treatments.

Transcription Process

US MDMD asst.Computer/ServerVoIP1-800FTP or TASPServerMTs

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Evolution and HistoryThe father of modern medicine, Hippocrates, had physician notes as a written record of medical actions and also served as a basic guide for reference for future patient care.

Evolution and History In the past, these reportings consisted of very abbreviated handwritten notes that were funneled into the patient's file for interpretation by the primary physician responsible for diagnosing ailments and prescribing treatment.

Ultimately, consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department.

Evolution and HistoryWhenever the need arose to review the records of a specific patient, the patient's file would be retrieved from the filing cabinet and delivered to the requesting physician.

To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy.

Evolution and HistoryIn the early 1900s, medical stenographers began taking dictation by shorthand; thereafter, dictation machines evolved. Virtually every visit to the doctor, every admission to the hospital, requires a comprehensive record of the encounter, including the diagnosis, treatment, and outcome. This is the material transcribed by the MT.

Evolution and HistoryIn the 1960s, the job title was medical secretary, the keyboard was a manual typewriter, the dictation was recorded on magnetic belts or plastic grooved disks, the standard reference was a Tabers dictionary, and transcription was done only within healthcare facilities.

Evolution and HistoryPhysicians came to rely on the judgment and reasoning of experienced medical secretaries to safeguard the accuracy and integrity of medical dictation, leading to medical transcription evolving into a medical language specialty.

Medical transcription is one of the most sophisticated of the allied health professions, creating an important partnership between healthcare providers and those who document patient care

Evolution and HistoryIn recent years things have changed considerably. Walls of filing cabinets have given way to desktop computers connected to powerful mainframe systems where patient records are prepared and archived digitally.

Evolution and HistoryIn recent years things have changed considerably. Walls of filing cabinets have given way to desktop computers connected to powerful mainframe systems where patient records are prepared and archived digitally.

Evolution and HistoryThis digital format allows for immediate remote retrieval by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises.

Evolution and HistoryWhile the transition from a paper based to an electronic format will take years to complete, considerable progress has been made. Handwritten reports are largely a thing of the past. Verbal dictation is now by far the most common method for documenting and reporting the results of examinations and procedures.

Evolution and HistoryPhysicians generally use either a cassette based voice dictation system or a digital voice dictation system to record their findings. Dictating reports verbally not only allows physicians to be more thorough in their reporting, it also saves them a great deal of time.

Why Medical Transcription?It flows from the need for documentation of medical records and the inability of hard-pressed doctors to sit and write those reports themselves.

Why Medical Transcription?medical insurance claims and lawsuits are decided on the documented case history makes this all the more necessary. doctors are frequently invited to deliver lectures at medical colleges implying the need to prepare extensive notes on case studies to be handed out to participating students.

Reports transcribedMedical records dictated by doctors or medical professionalsHistory & physical reportsClinic notesOffice notesOperative reportsConsultation notesDischarge summariesPsychiatric evaluationsLaboratory reportsX-ray reportsPathology reports

Why Medical Transcription?The boom in transcription over the past forty years is primarily due to reimbursement demands. First diagnosis-related groups (DRGs) and then Medicare and Medicaid, and finally, all reimbursement systems have demanded that diagnosis and procedure codes for reimbursement be substantiated by legible patient care documentation. Transcribed notes provide that legibility. This improvement over handwritten notes contributed to increased documentation by dictation and transcription.

Why Medical Transcription?As healthcare facilities felt increasing pressures related to reimbursement, they in turn faced increasing demands on their resources personnel, space, and equipment. Costs for transcription increased, and the appeal to turn over this demanding task to outside businesses became more and more attractive. These stimuli created big business, and medical transcription became an industry unto itself.

Why Medical Transcription?The Modern Healthcare TeamPhysiciansNursesPharmacistsTherapistsDietitiansTechniciansMedical TechnologistHealthcare information managerHealthcare EducatorsMEDICAL TRANSCRIPTIONISTS

Qualities of a Medical TranscriptionistWhat does a medical transcriptionists need to know?practical knowledge of medical language, anatomy, physiology, disease processes, pharmacology, laboratory medicineinternal organization of medical reportsaware of standards and requirements that apply to the health recordlegal significance of medical transcripts

Qualities of a Medical TranscriptionistWhat are the characteristics of a Medical Transcriptionist?The primary skills necessary for performance of quality medical transcription:extensive medical knowledge and understanding above-average knowledge of English punctuation and grammar excellent auditory skills versatility in use of transcription equipment and computers

Qualities of a Medical TranscriptionistWhat are the characteristics of a Medical Transcriptionist?The primary skills necessary for performance of quality medical transcription:advanced proofreading and editing skills, ensuring accuracy of transcribed material sound judgment and the ability to detect medical inconsistencies in the medical reporthighly developed analytical skills, employing deductive reasoning to convert sounds into meaningful form

Qualities of a Medical TranscriptionistKnowledge, Skills and Abilities RequiredKnowledge of medical terminology Transcription skills. Ability to sort, check, count, and verify numbers. Skill in the use of operating basic office equipment. Ability to follow routine verbal and written instructions. Ability to document work in progress. Records maintenance skills.

Qualities of a Medical TranscriptionistWhere are medical transcriptionists employed?

1. healthcare settings doctors' officespublic and private hospitals teaching hospitalsmedical transcription businesses clinics, laboratories, radiology and pathology departments insurance companies medical librariesgovernment medical facilities, rehabilitation centerslegal offices, research centers veterinary medical facilitiesassociations representing the healthcare industry.

Qualities of a Medical TranscriptionistWhere are medical transcriptionists employed?

2. work with physicians and surgeons in multiple specialties, pharmacists, therapists, technicians, nurses, dietitian, social workers, psychologists, and other medical personnel.

3. work at home as employees of transcription businesses or hospitals as independent contractors.

Qualities of a Medical TranscriptionistWhere are medical transcriptionists employed?

4. may become quality assurance specialists, supervisors, managers, department heads, or owners of medical transcription businesses.

5. Experienced medical transcriptionists may become teachers, working in schools and colleges to educate future medical transcriptionists.

Requirements for job application Graduates of Nursing, Medical Technology, Physical Therapy, oth#er allied health courses, or a medical transcription course from a reputable transcription school. With at least 1 year experience in Medical Transcription and 6 months in editing OR 2 years transcription experience. Must be able to produce off edit work to a level of 98% accuracy.

Requirements for job applicationMust be able to edit a minimum of 1,000 lines per day. Excellent hearing acuity and listening skills. Knowledgeable in basic computer operations and internet applications. Must possess excellent English communication skills, oral and written. Willing to work a 44 hour work week schedule. Willing to be assigned to any schedule.

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