Medical transcriptionists listen to dictated recordings made by physicians and other health care 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 health care 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. 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 health care providers transmit dictation to medical transcriptionists using either digital or analog dictating equipment. 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. 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, with standardized terminology are more likely to use speech recognition technology. However, speech recognition technology will become more widespread in all specialties as the technology becomes more sophisticated, that 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 also may transcribe as part of their jobs.
Work environment. The majority of these workers are employed in comfortable settings, such as hospitals, physicians' offices, transcription service offices, clinics, laboratories, medical libraries, government medical facilities, or their own homes. Many medical transcriptionists telecommute from home-based offices.
Workers usually sit in the same position for long periods. They can suffer wrist, back, neck, or eye problems due to strain and risk repetitive motion injuries such as carpal tunnel syndrome. The constant pressure to be accurate and productive also can be stressful.
Many medical transcriptionists work a standard 40-hour week. Self-employed medical transcriptionists are more likely to work irregular hours—including part time, evenings, weekends, or on call at any time.
| 1. | Transcribe dictation for a variety of medical reports such as patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation, and/or discharge summaries. |
| 2. | Review and edit transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology. |
| 3. | Distinguish between homonyms, and recognize inconsistencies and mistakes in medical terms, referring to dictionaries, drug references, and other sources on anatomy, physiology, and medicine. |
| 4. | Return dictated reports in printed or electronic form for physicians' review, signature, and corrections, and for inclusion in patients' medical records. |
| 5. | Translate medical jargon and abbreviations into their expanded forms to ensure the accuracy of patient and health care facility records. |
| 6. | Take dictation using either shorthand or a stenotype machine, or using headsets and transcribing machines; then convert dictated materials or rough notes to written form. |
| 7. | Identify mistakes in reports, and check with doctors to obtain the correct information. |
| 8. | Perform data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians. |
| 9. | Produce medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material. |
| 10. | Answer inquiries concerning the progress of medical cases, within the limits of confidentiality laws. |
| 11. | Set up and maintain medical files and databases, including records such as x-ray, lab, and procedure reports, medical histories, diagnostic workups, admission and discharge summaries, and clinical resumes. |
| 12. | Perform a variety of clerical and office tasks, such as handling incoming and outgoing mail, completing and submitting insurance claims, typing, filing, and operating office machines. |
| 13. | Decide which information should be included or excluded in reports. |
| 14. | Receive patients, schedule appointments, and maintain patient records. |
| 15. | Receive and screen telephone calls and visitors. |
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