It is the main task of medical transcriptionists to transcribe or write out the dictations recorded by physicians and other healthcare professionals. The information from these recordings is written down into different types of medical reports, correspondence or administrative materials. The documents transcribed and produced from the recordings include patient history and physical examination reports, discharge summaries, consultation reports, laboratory reports, diagnostic and imaging reports, operative reports, referral letters, pathology reports, progress notes and autopsy reports. These documents are edited and reformatted by medical transcription editors and sent back to the medical professional who dictated them for review or revisions. After the revisions and clarifications, these documents eventually become a part of the patient’s permanent medical files.
Medical transcriptionists listen to recordings through a headset. Using a foot pedal, they pause and resume with the recording when needed. As they listen to dictated recordings, transcriptionists key in the text into the computer and make the necessary revisions for grammar, clarity and consistency. Some recordings may not be clear or logical but medical transcriptions are expected to have the ability to understand and to accurately interpret what they hear. To avoid inconsistencies or irregularities, it is the responsibility of medical transcriptionists to refer to standard medical reference materials obtained from the Internet or from printed materials. Similar to medical or health care professionals working in the field, medical transcriptionists must also comply with the standards relevant to the medical records that are dealt with. They must also adhere to ethical and legal requirements by keeping the patient information and records confidential. Although alterations and revisions are done, transcriptionists must be cautious not to change any relevant detail and finding that may consequently produce inaccurate reports.
Medical transcriptionists are employed in hospitals, offices of physicians, laboratories, government medical facilities, transcription offices or from their own homes. Although the job may not be difficult as it seems to be, it may be a cause of different types of injuries, such as back pain, carpal tunnel syndrome and eye problems. A sedentary lifestyle with constant exposure to stress may cause health problems.
Medical transcriptionists are not only skilled typists with excellent listening and grammatical skills. They must also have a strong familiarity to the medical terminologies and language. Without the ability to translate medical jargon and abbreviations used in the recording, the reports may not be consistent or complete as they should be. For this reason, it is important to obtain the appropriate medical transcription training before employment.
Those interested to start a medical transcriptionist career should obtain the appropriate training offered by certain community colleges, vocational schools and distance-learning programs. Students may either complete a 1-year medical transcriptionist certification or a 2-year associate’s degree program before employment. Accreditation is not a requirement and medical transcriptionist schools have the choice whether or not obtain an accreditation from the Approval Committee for Certificate Programs or ACCP or from the American Health Information Management Association. It is recommended to enroll in programs accredited by these organizations as they may be required for a medical transcriptionist certification.