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Medical Transcription

Medical Transcription

By: Kevin

15 Nov 2010

Medical transcription is the process whereby voice-recorded reports of patients are dictated by physicians and/or other healthcare professionals and converted into text format. This is an allied health profession.

The two main types of instruments used in recording include a hand-held recorder or dialing into a regular telephone which is connected to a central server located in a hospital or transcription service office. These recordings are accessed by medical transcriptionists and converted into text.

Patients visit doctors/clinics/hospitals for reasons of consultation or followup. Every time a patient visits a doctor, the doctor uses a voice-recording device to record the details of the visit including current symptoms, past history, medications, allergies, etc. and also the current diagnosis and treatment plan. This transcript forms a part of a patient's medical record. This trail of transcripts help the doctors to have a clear idea of what has happened to the patient in the past and what future course of treatment is needed.

Patients may also get admitted into hospitals, undergo surgery, and may have laboratory and/or diagnostic studies. These are also similarly recorded in full detail. In case of admissions, an admission report, the hospital course and a discharge report detailing current symptoms, past history, medications, allergies, current diagnosis, and treatment plan are made. All laboratory and/or diagnostic reports are transcribed and a copy maintained with the medical records. Surgery is also transcribed in detail as to what was the surgical procedure done, what anesthesia was used, who was the surgeon, and the process of surgery itself.

There are specific formats necessary to be maintained while transcribing each type of medical files. Some of the rules are set by the Association for Healthcare Documentation Integrity (AHDI), which was formerly the AAMT, which was the American Association for Medical Transcription. The clinics/hospitals may of course have their own specifications of how a document is to be formatted and doctors may also specify individually how a document is to be formatted.

This transcript is also considered to be a legal document as this is one of the major evidences used in malpractice suits in the event of a patient brining in charges against a doctor indicating negligence in treatment and its untoward effects.

It is therefore very important that the transcript be properly formatted, edited, and reviewed. Think of the consequences if a wrong medication or the wrong diagnosis was typed. The patient would definitely be at risk if such errors were not spotted.

Doctors and transcribers have a role in ensuring the accuracy of the document. The doctor needs to dictate slowly and precisely while the transcriptionist should make sure that all the information contained within a report is consistent with the help of his/her knowledge of medical terminology. There is definitely no need to stress on the level of importance of acquiring medical knowledge, constantly updating this knowledge of both medical terminology as well as changes in the rules and regulations for transcription as stipulated by the governing bodies and having the know-how of researching for information which is not familiar.

The field of medicine is so vast that it would definitely be impossible for everyone to know every branch of medicine in minute detail. Just as doctors specialize in one field of medicine, many transcribers specialize in one field of medicine, though some transcribers do work on many branches of medicine.

Now, with the advent of speech recognition software a lot of the transcription is being done by machines, but yet human intervention is indispensable. Fast and garbled recordings and heavy accents as well as mumbling and numerous corrections and other instructions within a recording make it difficult for the machines to do an accurate job with the transcription. If speech recognition is used to do the transcription, then a transcriber still has to check the accuracy of the document. The importance of accuracy in a document which deals with life cannot be stressed enough. Hence, machines may be used to take the drudgery out of the medical transcription process but transcriber interference will be needed to ensure the final accuracy.

A medical transcriptionist requires many skills and abilities. To name them:
1. Extensive knowledge of medical terminology to include anatomy, physiology, diseases,
2. Excellent command over language skills such as spelling and grammar, punctuation, capitalization rules etc.
3. Being skilled in the computer and software usage as well as typing.
4. Coordination of foot (for playing audio using foot pedals), eye, and hands (for typing).
5. Multitasking - need to hear, understand, and type while ensuring that what is being typed is in context with the rest of the data.
6. Thorough knowledge of templates and other formatting instructions for each and every type of medical transcript be it a consult note, a followup, a presurgical note, operative note, an admission note, a discharge summary, history and physical, radiology report, pathology report, laboratory report, an emergency visit report, or an autopsy report etc. All the rules and regulations for each type of document as set out by the clinic/hospital, by the specific doctor as well as AHDI should be remembered.
7. Ability to spot inconsistencies in reports is crucial. For eg. in a presurgical report for kneed surgery, if the doctor talks about the right knee in one place and the left knee in another, then such inconsistencies should be spotted by the transcriber, flagged, and brought to the attention of the doctor for clarification. Think what would happen if a patient were to go in for left knee replacement and lands up with a right knee replacement!