KimHaas.com Transcription Coaching, Blogs and Articles
January 03 2010
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The Process of Medical Transcription Defined
Medical transcription is the process converting voice-recorded reports as dictated by physicians or other health care professionals, into text format.
The process of medical transcription is fairly simple. When the patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past history and health issues. The doctor then performs a physical examination and may request various laboratory or diagnostic studies, depending on the needs of the patient. Then, the doctor will make a diagnosis or differential diagnoses.
The patient and doctor then need to decide on a plan of treatment for the patient. They determine the best choice after explaining the procedure to the patient and discussing the benefits and dangers.
After the patient leaves the office, the doctor uses a voice-recording device to record the information about the patient encounter. The information generally recorded includes needs and illnesses of the patient, diagnosis, and any other relevant material.
This information may be recorded into a hand-held cassette recorder or into a regular telephone, dialed into a central server located in the hospital or transcription service office, which will ‘hold’ the report for the transcriptionist.
After being recorded, this report is then accessed by a medical transcriptionist. The recording that they receives is a voice file or cassette recording.
The medical transcriptionist listens to the dictation and transcribes it into the required format for the medical record.
The medical record they create is considered to be a legal document.The next time the patient visits the doctor, the doctor will call for the medical record. This medical record is also referred to as the patient’s chart, which will contain all reports from previous encounters.
From this medical record, the doctor can on occasion refill the patient’s medications. Although doctors prefer to not refill prescriptions without seeing the patient first, to thoroughly establish if anything has changed that may affect their medication.
It is vital to have a properly formatted, edited, and reviewed document. If a medical transcriptionist accidentally types in the wrong medication or the incorrect diagnosis, the patient could be at high risk.
To lessen this occurrence, doctors review the document for accuracy. Both the Doctor and the transcriptionist play an important role in ensuring the transcribed dictation is typed correctly and accurately.
The Doctor should speak slowly and concisely, especially when dictating medications or details of diseases and conditions, and the transcriptionist must possess hearing acuity, medical knowledge, and good reading comprehension, in addition to checking references when in doubt.
However, some doctors do not review their transcribed reports for accuracy. Often transcribed material will be read by doctors when using a computer.
The computer attaches an electronic signature with the disclaimer that a report is “dictated but not read”. This electronic signature is readily acceptable in a legal sense.
Medical transcriptionists are trained to do three basic things.
These three basic things include transcribing verbatim, make no changes to the medical document, but they have the option to flag any report inconsistencies.There are certain situations that may cause an increase chance of mistakes. On some occasions, the doctors do not speak clearly, or voice files are garbled.
Some doctors are, unfortunately, time-challenged and need to dictate their reports quickly. In addition, there are many accents and mispronunciations of words the medical technologist must contend with and understand in order to compile a transcription.
Because of this, transcriptionists need to have really good hearing and communication skills and it is imperative they be able to write well. A large part of the job of the transcriptionists is to look up the correct spelling of complex medical terms, medications, obvious dosage or dictation errors.
When they find a mistake or feel in doubt they need to fix it.
If it is just a basic mechanics problem they can easily fix that right on their computer.But if they suspect a medical error they should “flag” the report. A “flag” on a report requires the dictator to fill in a blank on a finished report, which has been returned to him, before it is considered complete.
Transcriptionists are never, ever permitted to guess in a report transcription. As the field of medicine is constantly changing there is always new equipment, new medical devices, and new medications that come on the market on a daily basis.
One needs to be creative and to be up on their medical knowledge and research to find these new words and any possible mistakes.
They should always have access to an up-to-date library to quickly facilitate the insertion of a correct word.Due to medical transcription, the medical world is more organized and less cluttered. With the help of them we will all have a better visit to the doctor.
About the Author:
Jack R. Landry has worked since 1991 as a medical transcriptionist providing hospitals, clinics, and large group practices with [url=“http://www.stattranscriptionservicesinc.com”]medical
transcription services[/url].Contact Info: Jack R. Landry .(JavaScript must be enabled to view this email address) http://www.stattranscriptionservicesinc.com
Posted by Kim Haas on 01/03 at 10:27 AM
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