Proper transcription of medical notes prevents errors.
Medical transcriptionists listen to dictated recordings by physicians and convert them into medical reports, which are eventually placed in the patient's medical record. Errors made while transcribing may lead to serious consequences for the patient, so accurate editing is critical. In order to properly transcribe medical records, individuals must enroll in a medical transcription program and obtain certification.
Instructions
1. Complete a medical transcription program. In order to properly transcribe medical records, individuals must enroll in either a one-year certificate program or two-year associate degree program through a community college or online medical transcription school. Make sure the school is accredited by the Association for Healthcare Documentation Integrity (AHDI).
2. Practice while in school transcribing reports from different medical specialties, such as cardiology, radiology and orthopedics, and become proficient in anatomy, diagnostic procedures and pharmacology.
3. Study transcription rules of style, which cover abbreviations, grammar, punctuation and spelling. Refer to "The Book of Style for Medical Transcription". Accurately transcribe diagnoses and medications by referencing a medical dictionary or the "Physician's Desk Reference".
4. Learn use transcription equipment and software. Become proficient with a computer, a foot pedal, the Internet, and Medical Spell Checker, Medical Abbreviation Expander and dictation software.
5. Proofread medical reports for inconsistencies and mistakes. These report formats include histories and physicals, consultations, office notes, surgical notes, pathology reports and discharge summaries.
6. Obtain the Certified Medical Transcriptionist (CMT) credential after finishing school. The certification exam is administered by the AHDI and is recognized as a sign of competence.
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