There once was a time when patient notes were mere piles of papers in ever-expanding physical patient file folders. Pertinent patient information was hard to find. Differing terminology from doctor to doctor often made doctor notes hard to fully understand. Absolute accuracy was not always possible.
As various 20th-century technologies came along, the medical transcription profession emerged, which quickly improved the situation and revolutionized healthcare. We’ll further explain this profession and why it is important.
What Medical Transcription is?
Medical transcription is the process of putting a doctor’s recorded verbal patient notes into a standardized, typed format online. Hospital transcriptions may include radiology, pathology, and/or laboratory information, as well as operation reports and discharge summaries. Office transcriptions include the patient’s history, initial evaluations, chart notes, referral letters, and/or patient introduction letters to specialists.
Clinics increasingly put the patient medical information onto an integrated electronic medical/health record, which enables medical professionals everywhere to access patient information.
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What Medical Transcriptionists Do and What They Know
Medical transcriptionists also referred to as medical transcribers (MT) or medical language specialists (MLS) use a dictation machine that has a foot pedal. The machine enables the MT to start and stop playing the cassette as needed. Medical transcription work sounds simple, but it requires considerable training, near perfection in its execution, and HIPPA compliance.
All medical transcriptionist students should already possess above-average skills and abilities in administration, spelling, and in other particular areas when they start transcription training. Medical transcription training is grueling. Only top performers are certified.
MTs create reports and things in a standard format. MTs know many medical terms and are familiar with human anatomy, disease processes, medical procedures, and equipment. This level of familiarity is crucial to accurately transcribe medical information spoken by foreign-born doctors who speak with thick accents.
MTs who specialize become very familiar with the specialty’s unique terminology and procedures. Specialization leads to optimum performance. For example, transcribers who mainly transcribe information daily that has to do with, say radiology, deliver the best radiology transcription service.
Voice/speech recognition computer software is sometimes used by doctors to cut costs, but it cannot reason how to handle a doctor’s poor speech habits or decipher his mumbled words or thick accent. Its shortcomings create room for error, necessitating MTs to perform as medical editors.
Why Medical Transcription is Important?
All transcribers free up time for their employers to do other important tasks. In the case of medical transcription, once a doctor has dictated patient notes onto a cassette and passed the cassette on to their MT, he can spend his time performing duties that are more in line with his level of education.
When medical transcription emerged as a profession, it provided the perfect opportunity to standardize both medical terminology and reporting. Standardization does the following:
- Improves the understanding of medical information that comes from other healthcare professionals
- Enables quick access to any kind of patient healthcare information a healthcare professional would want to know, such as allergy information
- Prevents duplication of data
- Helps researchers
- The online nature of medical transcription results in the following:
- The availability of patient information to doctors and insurance companies
- The ability to print off a hard copy of patient information for convenience
- The freeing up of floor space that’s no longer needed for cabinets full of patient file folders
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The widespread use of computers in medical facilities facilitated the emergence of the medical transcriptionist profession. Medical transcription has solved many problems. It has freed up doctor time, standardized medical terminology and reporting, and has taken full advantage of computer technology.