What is a Medical Transcriptionist

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Medical transcriptionists 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, medical history and physical examination reports, operative reports, consultation reports, autopsy reports, diagnostic-imaging studies, progress notes, and referral letters. Medical transcriptionists 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, medical transcriptionists 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, transcriptionists refer to standard medical reference materials—both printed and electronic; some of these are available over the Internet making a work from home situation possible. Medical transcriptionists must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for keeping patient information confidential.

Experienced transcriptionists 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 use either digital or analog dictating equipment to transmit dictation to medical transcriptionists. The Internet has grown to be a popular mode for transmitting documentation. Many transcriptionists receive dictation over the Internet and are able to quickly return transcribed documents to clients for approval. Also, because of the popularity of using the Internet to transmit documentation, many medical transcription departments are beginning to work closely with programmers and information systems staff to stream in voice communication that provides seamless data transfers through network interfaces. This practice allows medical transcriptionists the convenience of having hand-held personal computers or personal data assistants (PDAs) that utilize software for dictation.

Another increasingly popular method uses speech recognition technology, which electronically translates sound into text and creates drafts of reports. Transcriptionists then format the reports; edit them for mistakes in translation, punctuation, or grammar; and check for consistency and any wording that doesn’t make sense medically. Transcriptionists working in specialties such as radiology or pathology, which have standardized terminology, are more likely to use speech recognition technology, a medium that will become more widespread in all specialties as it becomes more sophisticated and is better able to recognize and more accurately transcribe diverse modes of speech.

Medical transcriptionists who work in physicians’ offices 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, also may perform transcription as part of their jobs.

source: U.S, Department of Labor

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