Medical Transcription

Candice B. Relieve, M.D.

 • The process of converting voice
dictation into a permanent written
record utilizing word processing
What is Medical

equipment and software.

• Each day in hospitals, thousands of
patients are admitted and
discharged.
– Examinations are conducted,
procedures are performed and
recommendations are made.
 • Each patient-related activity and
procedure must be meticulously
documented and then added to the
What is Medical

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.
 • Over time, all of this
information accumulates in a
centralized medical records
What is Medical

repository where it serves as a

critical resource for patient care
- facilitating accurate diagnoses
and appropriate treatments.
Transcription Process

Computer/Serv
er

Server MTs
US MD
MD asst. FTP or TASP

VoIP
1-
800
 • The father of modern medicine,
Evolution and History

Hippocrates, had physician

notes as a written record of
medical actions and also
served as a basic guide for
reference for future patient
care.
 • In the past, these reportings consisted
Evolution and History

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.
 • Whenever the need arose to review
Evolution and History

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.
 • In the early 1900s, medical
Evolution and History

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.
 • In the 1960s, the job title was
Evolution and History

medical secretary, the keyboard

was a manual typewriter, the
dictation was recorded on magnetic
belts or plastic grooved disks, the
standard reference was a Taber’s
dictionary, and transcription was
done only within healthcare
facilities.
 • Physicians came to rely on the
Evolution and History

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
 • In recent years things have
Evolution and History

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.
 • This digital format allows for
Evolution and History

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.
 • While the transition from a paper
Evolution and History

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.
 • Physicians generally use either a
Evolution and History

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.
 – Medical records dictated by doctors or
medical professionals
Reports transcribed

– History & physical reports

– Clinic notes
– Office notes
– Operative reports
– Consultation notes
– Discharge summaries
– Psychiatric evaluations
– Laboratory reports
– X-ray reports
– Pathology 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 Team
– Physicians
– Nurses
– Pharmacists
– Therapists
– Dietitians
– Technicians
– Medical Technologist
– Healthcare information manager
– Healthcare Educators
– MEDICAL TRANSCRIPTIONISTS
 • What does a medical transcriptionists
need to know?
Qualities of a Medical

– practical knowledge of medical language,

anatomy, physiology, disease processes,
Transcriptionist

pharmacology, laboratory medicine

– internal organization of medical reports
– aware of standards and requirements that
apply to the health record
– legal significance of medical transcripts
 • What are the characteristics of a Medical
Transcriptionist?
– The primary skills necessary for
Qualities of a Medical

performance of quality medical

Transcriptionist

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
 • What are the characteristics of a Medical
Transcriptionist?
– The primary skills necessary for
Qualities of a Medical

performance of quality medical

Transcriptionist

transcription:
• advanced proofreading and editing skills,
ensuring accuracy of transcribed material
• sound judgment and the ability to detect
medical inconsistencies in the medical report
• highly developed analytical skills, employing
deductive reasoning to convert sounds into
meaningful form
 • Knowledge, Skills and Abilities
Required
– Knowledge of medical terminology
Qualities of a Medical

– Transcription skills.
Transcriptionist

– 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.
 • Where are medical transcriptionists
employed?
1. healthcare settings
Qualities of a Medical

• doctors' offices
Transcriptionist

• public and private hospitals

• teaching hospitals
• medical transcription businesses
• clinics, laboratories, radiology and pathology
departments
• insurance companies
• medical libraries
• government medical facilities, rehabilitation
centers
• legal offices, research centers
• veterinary medical facilities
• associations representing the healthcare
industry.
 • Where are medical transcriptionists
employed?
Qualities of a Medical
Transcriptionist

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.
 • Where are medical transcriptionists
employed?
Qualities of a Medical
Transcriptionist

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 application
• Must 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.