Inside Medical Transcription

The professional healthcare team includes physicians, nurses, therapists, technicians, dieticians, and other healthcare support staff. A vital member of this team is the medical transcriptionist. While not as visible to the general public as those members of the team providing hands-on care, the medical transcriptionist plays an important role in documenting the quality of patient care.

Medical transcriptionists provide an important service to both physician and patient by transcribing dictated medical reports that document a patient’s medical care and condition. These may include office chart notes, history and physical examinations, consultations, letters, memos, admission notes, emergency department notes, operative reports, discharge summaries, and many specialized laboratory tests and diagnostic studies. Medical transcriptionists transcribe reports from a variety of medical specialties, and each day’s work presents a unique challenge and opportunity for learning.

Medical transcriptionists contribute to quality patient care through their commitment to excellence. Because each dictated report represents a part of a patient’s life, the medical transcriptionist transcribes it with care, demonstrating an extensive knowledge of medical terminology, anatomy, pharmacology, human diseases, surgical procedures, diagnostic studies, and laboratory tests in order to produce an accurate and complete permanent medical record.

A mastery of English grammar, structure, and style, a knowledge of transcription practices, skill in typing, spelling, and proofreading, and the highest professional standards contribute to the medical transcriptionist’s ability to interpret, translate, and edit medical dictation for content and clarity.

Medical transcriptionists work in a variety of settings, including medical centers, general and specialty hospitals, clinics and group practices, radiology and pathology offices, government facilities, insurance companies, home offices, and other environments. Some medical transcriptionists combine their transcription skills with clinical skills to work as medical assistants. Others become supervisors, managers, and college teachers.

The medical transcription field is certainly one that is scheduled for continued growth and over the next twenty to thirty years. Transcript companies know that with the aging of the baby boom population, doctors and hospitals alike are determined to continue to provide a demand for these valuable services. But when it uses a medical transcription company, you must stop to ask yourself what are precious these services when they are generated by the outsourcing of medical transcription companies.

It is imperative that physicians dictate notes for a patient files while it is still fresh in their minds. By the same token, it is equally important that the records are reproduced below as quickly and efficiently. Many are still wondering whether the eruption of medical transcription, outsourced companies will stop this requirement dead in its tracks.

Medical transcription can be a complicated game. There are many times when the translation of a doctor’s dictation can be tough. Even simple things such as regional accents transcribers can give a headache. But it is so important for healthcare providers and patients alike have records transcribed and placed in text format in a timely manner. This ensures that information and reports are efficient and accurate, and have the best interests of the patient and his family in mind.

Receiving health care in the transcript in a timely manner is also a major concern when people begin to argue with the figures of outsourcing medical transcription. Not only is there concern about whether the medical transcribers overseas can effectively translate documents and voice recordings of americas doctors and administrators, but there are also more concerned about the speed with which work can be turned around and generated a well-organized
patient records.

Records of patients must be given quickly, so that the information is still fresh for the doctor. The same applies to the transcript. There needs to be a small window of time for that to happen, so if there are any problems or red flags to be addressed, hopefully the doctor in question will best remember the case. This may be a problem when it comes to medical transcription outsourced.

Besides efficiency, there are further doubts about whether or not outsourced medical transcription can accurately reflect the physician and medical notes that are so essential to a patient files. Even within the United States there are regional dialects and accents that can give even seasoned members of the medical transcription field a run for his money. Imagine the problems that can arise when the transcript is being made only by those who have English as a second language, as in the Philippines, where the medical transcription field is booming due to the outsourcing of the United States. Problems in patient records may arise almost immediately when the transcript inappropriate, to say nothing of their potential detriment to a patient’s health. You should really be careful about their doctors and the services they are using, and work hard to make sure you’re getting the best possible care of the patient at each end of the spectrum.

It’s very important that their doctors’ transcription company provides information and completed the work to him and her in a timely and effective manner. You want the medical transcription company to be reliable and safe so you can receive the best care possible. This includes not only reliable with the transcript, but having the ability to work during his time quickly. It is essential that this happens to their health and their family.

Flagging a medical report is necessary when a Medical Transcriptionist leaves a blank or has some other question about a report.

It is important to learn and follow the department or employer’s policy for handling questionable dictation. Most employers insist that their Medical Transcriptionist leave blanks rather than to guess or make up dictation to avoid leaving a blank.

Consider the following steps as a customary hospital and clinic policy for leaving blanks and flagging:

*Seek the supervisor’s opinion or that of another Medical Transcriptionist
*Refer to the patient’s chart if available
*Contact the dictating physician to ask about the word in question. This is often handled by the supervisor or lead transcriptionist
*Leave a blank in the report and attach a flag to the dictator’s attention

You will probably get different responses from different physicians. Some physicians may give you information above and beyond what you ask for, which may include entire articles out of texts or journals to answer your questions. Other physicians will simply write the words on your flagging note.

A problem you will encounter with posting notes is those that are paper clipped to the report or a post-it
note can fall off. Notes need to be worded in an extremely tactful manner. The person to whom the note is directed can take offense when none is intended.

Another problem is most likely the Medical Transcriptionist will never see the printed copy of their reports. Printers are often in another location and another person is assigned to sorting and charting. One solution is to create a standard memo to accompany the report just like another page of the report. The memo may include:

*Patients name
*Other pertinent information
*Boxes or blanks to check for the problem encountered and a place to fill in the sounds like.

In either case as with using sticky notes or a standard memo, it is always important to remember the professional Medical Transcriptionist who desires to produce the most accurate, highest quality report possible will leave a blank and will learn from each blank he or she has to leave in medical dictation.

I have worked in both types of environments, one in which we all used a note paper clipped or a sticky note and the other where there is a standard memo attached to each transcribed report that floats along as part of the entire document wherever the report goes.