Medical Transcription is the typing of documents from dictated recordings by health professionals. Basically any type of medical treatment ,procedure, diagnostic tests etc must be documented into patient’s permanent medical record. In order for this to be done in a legible accurate fashion, health professionals dictate this specific information either into a digital or analog recorder and/ or through the use of a phone dictation system.
Transcriptionists then transcribe this information into a typed document, which is then forwarded to the dictator for review and signature. These documents then become part of a patient’s permanent medical record.. To understand and accurately transcribe this dictated information into a document that is both accurate and coprehensible to the reader a medical transcriptionist must have an in-depth understanding of medical terminology, anatomy, physiology, procedures and treatment. Also able to understand abbreviations and have the ability to reference terms through the use of printed and electronic reference materials.
There are basic qualities and skills that a Medical Transcriptionist requires. Following are few of the skills needed:-
- Typing speed– It is important in the productivity of a transcriptionist. Techniques for building speed and efficiency on the key board is an invaluable tool for improving typing speed and thereby productivity. Usually the industry requirement is 60-80 wpm (words per minute)
- Language and Grammar style– The ability to correctly structure and punctuate proper English sentences is vital in producing quality Medical Transcription reports. Hence, transcriptionists need to have a thorough idea on when and how to use commas, semi colons, hyphenation, capitalization, subject – verb agreement and more.
- Medical Terminology – Understanding the language of medicine is essentially the most important and vital aspect of this career. Hence a constant improvisation on adding medical vocabulary is a must for a successful Medical
- Human Anatomy, Physiology and Disease Processes – Last but not the least , a general understanding of the human body and how it works is essential to medical transcription. Though not a thorough but a basic idea of all major body systems like musculo-skeletal system, Cardio vascular System (CVS), endocrine system, reproductive system, digestive system,respiratory system,the brain and Central Nervous system and the sense organs including their functions,organs, common diseases is required. These enable Medical Transcriptionist’s to formulate an understanding of the terms they will hear based on logic.
- Good listening skills– MT’s must be good at listening. The listening skill is a must for correct Transcription.
- Research skills– A medical Transcriptionist must have excellent research skills. Physicians will abbreviate words and phrases and you must know where to look for the meanings of the abbreviations.
ETHICAL AND LEGAL RESPONSIBILITIES
When dealing with confidential medical information, one must adhere to the highest ethical and privacy standards. Medical transcriptionists deal with confidential information everyday in the performance of their job, transcribing a physician’s spoken dictation into typed, easy to read notes. This means that medical Transcriptionists must have a clear understanding of the legal and ethical issues that affect them.
- He should be aware of HIPAA laws that affect them. HIPAA, the acronym for the Health Insurance Portability and Accountability Act of 1996, set down rules that must be followed when dealing with confidential medical inforation.
- It also regulates the ways in which confidential medical information can be shared and who may have the access to the information.
- If confidential , individually identifiable medical information is released improperly the result could include fines, the loss of the violator’s medical license jail time or civil suits.
Therefore it is important that medical Transcriptionist’s treat the information they work with a secret and protect it from any unauthorised people. MT’s should regard themselves as patient advocates. By careful and meticulous transcribing, MT’s help to reduce medical errors and misdiagnosis. Quality Medical Transcriptionist’s help the patient to get best medical care possible. It is MT’S duty to clarify any unclear term or unfamiliar medical diagnosis before transcribing it. This can be done by consulting the library of medical reference materials, discussing the questionable term with a more experienced medical transcriptionist or requesting the clarification from the physician or a person dictating the note in question.
Accurate and timely transcriptions will ensure that the patient’s chart is up to date and correct which ensures the best possible medical care for each patient. This way should an emergency arise all the patient’s most current medical information is present in the chart and is accurate and legible. When an ethical dilemma arises the Medical Transcriptionist (MT) has the duty to seek such clarification. First of all discussing the situation with a supervisor or a mentor is one way to gain clarity regarding the situation and help Medical Transcriptionist decide what their next step must be, if it doesn’t work, the MT can go to a professional organization such as American Association of Medical Transcriptionist’s. It is the MT’s responsibility to make sure that the ethical dilemma is resolved in the best way for all involved especially the patient.