Medical transcription is a complex task.
Medical transcription is the process by which an individual takes recorded medical notes and creates a written manuscript. Transcriptionists receive recordings from doctors. Using an electronic transcriber, headphones and foot pedal, the transcriptionist types into a word processor. The foot pedal allows the recording to slow down, speed up and backspace, freeing hands for typing.
Successful transcriptionists master several essential skills. No licenses are required. However, the Association for Healthcare Documentation Integrity (AHDI) provides a voluntary certification test for transcriptionists.
Learning independently is do-able for some, but usually for those with backgrounds in a medical field. For example, an individual who began but did not complete a nursing program would be a good candidate. Those without this type of background would have a difficult time hearing medical terms; spelling them; and understanding by the medical context whether they are writing the correct term. Health care providers and medical records departments require strict accuracy.
History
The first transcription was done by hand.
Keeping meticulous patient records is an essential aspect of medical care. During the 19th century, medical records processes evolved from doctors keeping their own notes to transcriptionists taking dictation. Notes were placed in patient files and carbon copies were made. Cabinets with files often filled whole rooms.
The invention of the typewriter, and later computer and recording devices made the process more efficient. Electronic files take up significantly less space--and copying is a snap.
Misconceptions
Medical transcriptionists must understand medical and pharmacology terms.
Some think transcription is easy, only involving technical skills such as use a transcriber. According to AHDI, transcriptionists should have strong grammar skills, interest in the medical field, knowledge of medical terminology, a basic understand of anatomy, physiology and pharmacology, technical and research skills, strong keyboarding and listening skills, critical thinking and an ability to focus.
Additionally, medical transcriptionists are expected to understand the context of various medical conditions, treatments and medicines.
Significance
Accurate medical records save lives.
Most of us understand the need for accurate medical records. A skilled transcriptionist is a vital part of the medical records team. According to the American Academy of Pediatrics, accurate medical documentation is a good defense against a malpractice accusation.
For the patient, precise medical records can mean the difference between life and death, or quality of life.
For safety, once the transcriptionist completes a document, the physician checks it for accuracy and may ask for changes that clarify. The transcriptionist makes the changes, and the doctor re-checks. The medical records supervisor will also check before filing it away.
Types of medical transcription
Transcriptionists must understand multiple specialties and accents.
Medical transcriptionists may specialize in chiropractic, obstetrics, podiatry, etc.
Evolving technology has opened up a new facet of medical transcription--the medical editor. The medical editor edits and formats documents produced by voice recognition software.
Transcriptionists may also become managers of medical records departments or physician offices.
Considerations
Choose training wisely or understand the risk.
Those who think they may want to work as a medical transcriber must first assess their skill levels. Which skills will need to be learned from scratch? For example, an experienced typist with a speed of 60 wpm or more will not need to learn keyboarding.
Personality and working styles should be examined as well. Someone who needs to have interaction throughout the day to feel fulfilled will probably not be happy as a transcriptionist. Transcriptionists work alone most of the day.
Contact a professional organization for resources such as books, certification info and recommended training programs.
Even if learning medical transcription independently is do-able, it might be a good idea to get a credential to become viable professionally.
Another good possibility is to work for a temporary agency. The agency tests candidates and this becomes a type of credential. Temporary jobs provide experience.
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