Medical transcription (MT) is the process by which medical records such as patient history, consultation, pathology and other reports dictated by doctors and other medical professionals are transcribed from audio to text format. The medical transcriptionist is the person who transforms audio medical reports from the original dictated form to the written form as either a soft copy or a hard copy. Medical transcriptionist is responsible for creating the written records. Therefore, it is obvious that he must be very careful while transcribing it.
Medical transcription is the primary mechanism for a physician to communicate with other healthcare providers who access the patient record to advise them on the state of patient’s health and about past and present treatment of the patient.
Areas where MTs should be careful
Medical transcriptionists translate dictated medical reports into printed formats. Working with physicians and other health care professionals, transcriptionists are responsible for the accurate and timely completion of medical reports including history, consultations, pathology and operative reports, chart notes and correspondence.
It is very important to have a properly formatted, edited and properly reviewed medical transcription document. If a medical transcriptionist accidentally typed a wrong medication or wrong diagnosis, the patient could be at risk. It is both the doctor and medical transcriptionist should ensure that the transcribed dictation is correct and accurate. The doctor should speak slowly and clearly while dictating medications or details of disease and conditions and the medical transcriptionist must possess hearing acuity, medical terminology and good reading comprehension in addition to checking references when in doubt.
Accuracy is of prime importance and speed is always secondary to accuracy. A Medical transcriptionist should constantly update himself by researching latest medical tools, medical language and equipments, so that he will provide the best results to medical professionals and medical companies.
Medical transcriptionists have to look up every single word, whether English or medical till they are 100% certain. MT requires correct spelling of all terms and words, correcting medical terminology and occasionally dictation errors. All transcription reports must comply with medico-legal concerns, policies, procedures, and laws under patient confidentiality.
Sometimes while dictating, doctors may make mistake or may give contradicting statements due to slip of tongue and it is up to the transcriptionist to be alert to all such issues and correct such mistakes done by the physician.
Medical transcriptionist is responsible for creating medical records. So it is obvious that he must be aware of medical terminologies and he should be careful that medical records prepared by him should follow medical transcription standards. Some of these standards are AHDI (Association of healthcare documentation integrity) and MTIA (Medical Transcription Industry Association).