Thanks to medical transcription, healthcare professionals and hospital centres have patients' medical records, with all their symptoms, diseases, diagnoses and treatments.
Today, there is a great demand for this service, and since it is a specialized type of transcription, there is less competition in the job market, and the rates they pay are higher.
Interested in learning more about medical transcription and finding out if it's for you?
Then read on, we tell you what it is, brief history, tasks, skills and how to become a medical transcriptionist.
What is medical transcription?
Medical transcription is the activity carried out by medical transcriptionists, which consists of converting into text all the reports, procedures and diagnoses made by medical specialists when treating a patient.
They are also in charge of creating files with lecture notes, recordings of doctors, research and any other material related to the world of medicine; all this information in audio files, videos or notes is converted by a transcriptionist to text and stored physically and digitally.
Nowadays, this transcription activity has been strongly impacted by the presence of software with artificial intelligence.
These software have been designed to optimize medical transcription, achieving the highest, most accurate, up-to-date information for patient care and consultation services.
Brief history of medical transcription
As medical research developed, it became necessary to establish standards and models for collecting all the information generated.
In the past, physicians prepared reports consisting of handwritten notes that were added to the patient's file, thus forming a record of each patient's diagnoses, procedures and medication.
At the beginning of the 20th century, this information began to be collected in an organized manner, with the assistance of stenographers who, being close to the physicians during consultations and surgical procedures, took notes of what was said when attending a patient.
With the emergence of voice recording devices, the transcriptionist was no longer necessary to be present with the physician; this was an important advance because the transcription could be done at another time.
We went from typewriters to word processors, and computers arrived; transcription equipment and storage methods changed today to digital recording and voice recognition technology for medical transcriptions.
Medical transcription duties and process
Here, we tell you about the tasks and processes carried out by medical transcriptionists.
Tasks
- Medical transcription aims to record as faithfully and accurately as possible all information provided by doctors, nurses and other healthcare specialists during patient care.
- By reviewing and editing transcripts, ensure the correct use and accuracy of medical terminology when using speech recognition applications.
- Keep track of patient medical records to facilitate quick and timely access to all relevant information.
Process
The process starts with the medical consultation when a patient attends and discusses his symptoms with the professional; in this meeting, a diagnosis can be reached, or tests are recommended to get it.
When the patient leaves the office, the physician records the patient care information using voice recording, usually a recorder or a smart device.
This step is crucial; the physician must speak slowly and clearly, especially when informing about the diagnosis of the disease and drug treatment.
Typically, the recording is connected to a central hospital server or the transcription service office; the transcriptionist accesses the information, listens to it and transcribes it in the established format.
This creates a medical record that is considered legal. The next time the patient attends a consultation, the physician will request and review the history of the last talk, or the patient's complete file with all the reports of previous consultations.
In the process, it is essential to have a formatted, edited and reviewed transcription document to avoid any errors; in this sense, both the transcriptionist and the physician play a key role in ensuring that the transcription is correct and accurate.
What is a medical transcriptionist, and his/her main tasks
In this section, we tell you what a medical transcriptionist is and the main lessons he/she performs.
What is a medical transcriptionist?
A medical transcriptionist is a transcriptionist who transcribes voice records made by physicians and other healthcare personnel when treating a patient in a healthcare facility or private practice; they convert all the information into a written document.
Medical transcriptionists may be employees of healthcare facilities, hospital telecommuters, or independent contractors for transcription services.
These professionals must ensure that they make a complete and accurate record of the diagnosis, treatment, medication and follow-up care of the patients seen, using the voice notes dictated by the treating medical staff.
What are their primary tasks?
- Be sure to record all information generated by the patient's attending to make a clear and organized record of the visit.
- Use your extensive knowledge of medical terminology or consult appropriate medical library sources to avoid making errors when transcribing.
- If you find inconsistencies in the information, use your knowledge, skills, and experience to clarify the data and ensure the records' accuracy.
- Review the transcription for accuracy and consistency to ensure the quality of care given to the patient.
- Do not make changes or omissions; write exactly and ultimately what is said in the voice records created by the treating staff, the physician in charge will be in order of validating or not the transcribed text.
- Edit the file and compare it with the audio files to ensure the accuracy of the transcribed information.
- After editing and review, file the medical records to be available and easily accessible at the next visit or to be sent to another health centre if necessary.
Skills needed to be a medical transcriptionist
Medical transcriptionists need to develop skills that will enable them to become good transcriptionists. Academic and practical preparation is essential and is obtained with medical terminology, anatomy, physiology, medical specialities, pharmacology and diagnostic studies courses.
Additionally, develop good auditory processing skills and understand accents and different tones so as not to be confused by the terminology used.
Another skill to develop is focus and attention; this will allow you to detect and resolve any contradictory information. In addition, it is essential to listen and write simultaneously, mainly if the need arises to be present at an examination or a surgical procedure.
How to become a medical transcriptionist
Acquiring knowledge and skills through education and training in medical transcription is imperative. It is possible through certification or diploma programs, distance learning or training in some hospitals.
There are excellent medical transcription training programs on the market, usually requiring a high school diploma, which can be obtained from vocational schools or community colleges.
In addition, the applicant must be fluent in English or any primary language of the healthcare system, have an excellent understanding of medical terminology, and have good listening and typing skills.
Applicants can become certified medical transcriptionists through the Association for Healthcare Documentation Integrity (AHDI), which offers the Registered Healthcare Documentation Specialist (RHDS) certificate and the Certified Healthcare Documentation Specialist (CHDS) certificate.
Many transcriptionists take courses in medical terminology, anatomy, physiology, medical specialities, diagnostic studies and pharmacology, and medical and surgical procedures for more comprehensive training and to earn higher rates.
Conclusions
Medical transcription is essential for physicians, other professionals and stakeholders in the healthcare system because it documents the entire patient care process efficiently and accurately.
Medical transcriptionists are increasingly in demand in the industry today, and more services and software are being developed to increase profitability.
The trend in the industry is to outsource medical transcription services and perform transcription using speech recognition technology.
These new automated service technologies, through speech recognition and significant editing resources, will most likely take medical transcription to higher levels of efficiency.
