Medical Transcription

Medical transcription (MT) is the process by which medical records - such as patient history, consultation notes, lab reports, and pathology reports - dictated by doctors and other medical professionals are transcribed from audio to text format. The medical transcriptionist is the person who transforms audio medical reports from the original dictated form to the written form to be produced either as a hard copy or to be stored in a computer system.

Job profile

The primary task of the medical transcriptionist is to transcribe, format and proofread medical records. Medical records for transcription are primarily sourced from the USA. They are outsourced for transcription from a variety of healthcare settings including doctor's offices, private/public hospitals, clinics, laboratories, legal offices, veterinary and medical clinics, research centres. Dictations are done not only by doctors but also by surgeons, nurses pharmacists, therapists, nurses and other paramedical staff. Medical transcriptionists receive the doctor's dictation by tape, digital systems or as a voice data file. Digitised data through the Internet is the most common means of receiving medical data from the USA.

The local transcription company receives the data and they uncompress it. At this point, the medical transcriptionist takes over. Using a suitable word processing programme/application the audio file is transcribed and edited. There are two stages in MT. The first is the actual process of transcription by a medical transcriptionist. This is followed by proofreading and editing. The MT industry employs a number of proofreaders, junior and senior editors as well. Proofreaders and editors perform the following functions:

Visual proofreading
Electronic spellcheck
Grammar check
Checking for medical inconsistencies and inaccuracies
The medical record - now in text form - is then routed back to the concerned doctor or hospital.

Hierarchy

A typical MT firm is structured as follows:

Trained medical transcriptionists
Senior medical transcriptionists
Proofreaders
Sub editors
Editors
Supervisor
Manager

Remuneration

At the entry level trained medical transcriptionists earn around Rs 3500-5000 per month. With a minimum of six months experience medical transcriptionists can expect to earn Rs.10,000 per month.

Essential Attributes

Medical transcriptonists must possess the following essential attributes:

Familiarity with medical jargon
Good typing skills
Excellent listening skills
Excellent command over English
Ability to adjust to different accents and diction
Ability to deduct medical inconsistencies in dictation
Ability to work long hours
High level of concentration over long periods of time
Training

MT schools offer certificate courses in transcription. Fees for short term (3-6 months) courses range from Rs.20,000-30,000. In-house training programmes are also offered by transcription firms that hire freshers.

Medical transcription training modules cover the following subjects:

English grammar
Medical terminology
Human anatomy
American English
Growth prospects

Medical transcription was initially an in-house affair completed within the four walls of the doctor's office or hospital itself. The advent of high-speed satellite links and the lower costs of outsourcing have brought the MT industry to countries such as India and Mexico. Over the last two years, India has become the hub of the global MT industry. MT is currently classified as an IT enabled industry and being actively promoted by NASSCOM's Vision Group for IT Enables Services.

In '98 alone, The Indian MT industry generated Rs.140 crore worth of tax-free foreign exchange. NASSCOM predicts that the turnover is likely to touch the Rs.10,000 crore mark by 2008.An estimated 1,60,000 medical transcriptionist are expected to be employed by the industry which currently employs one-fifth that number.

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Medical Transcription Curriculum

Any educational program in medical transcription should provide basic knowledge and skills required for transcribing healthcare dictation. The program’s aim should be to prepare a student for entry-level employment as a medical transcriptionist in the industry. It is recommended that the training program should ideally be based on ‘The Model Curriculum for Medical Transcription, 2nd edition, published by AAMT’ that specifies the below-mentioned requisites for a successful training program. These include: a minimum of 400 hours of theory classes & 600 hours of practical sessions with live dictation – a total of 1000 hours and should be delivered in regular batches over a period of six months. The important heads to be covered in the syllabus are:

1. English Language and its applied usage, which should cover correct English usage, rules of grammar, punctuation, and using correct spelling and sentence structure.

2. Medical Knowledge:

a. Understand medical terminology related to anatomy, physiology, general medicine, general surgery, medical specialties, surgical specialties, diagnostic and interventional procedures, pathology and laboratory medicine, health and wellness, imaging techniques, medications, and alternative or complementary medicine.

Medical language and its structure including prefixes, suffixes, combining forms, root words, plurals, abbreviations, acronyms, eponyms, homonyms, antonyms, synonyms, and commonly used phrases.

b. Anatomy and Physiology – Essentials of human anatomy and physiology.

c. Pharmacology and Laboratory Medicine

d. Common tests used in pathology and laboratory medicine, including diagnostic indications, techniques, expression of values, and significance of findings.

e. Recognize, pronounce, spell, define, and understand pharmacological terminology.

f. Drug classifications, indications, contraindications, actions, interactions, side effects, forms, dosages, and routes of administration.

g. Disease Processes, their etiology and pathology.

h. Clinical medicine, including diagnosis and treatment of common diseases and conditions.

i. Advanced Medical Language-surgical procedures and other diagnostic and interventional treatment modalities, including anesthesia types and techniques, surgical techniques, equipment, instruments, and accessories, as well as typical findings and related diagnoses.

j. Procedures, techniques, and findings in diagnostic and interventional imaging.



3. Computer skills and technology:

a. Word processing, computers, dictation and transcription equipment, and related technologies.

b. Operate designated dictation and transcription equipment and use designated word processing programs and related technologies.

c. Trends and developments in technologies related to healthcare documentation.

d. Use of electronic references and other resources for research and practice.



4. Healthcare Documentation:

a. Healthcare Records - the purpose and content of the healthcare record (paper and electronic).

b. The content and format of healthcare documents (paper and electronic).

c. Knowledge of standards and regulations related to healthcare documentation as set by US healthcare authorities.

d. Medicolegal Concepts and Ethics-the medicolegal aspects of the healthcare record (e.g., confidentiality, privacy) and the medical transcriptionist's role in risk management.

e. Understanding and application of ethics in the medical transcription profession.



5. Professional Practice:

a. Fundamentals of Medical Transcription

b. Demonstrate the ability to proofread and correct transcribed healthcare documents.

c. Recognize, evaluate, and interpret inconsistencies, discrepancies, and inaccuracies in healthcare dictation and appropriately edit, revise, and clarify them while transcribing, without altering the meaning of the dictation or changing the author's style.

d. Meet progressively demanding medical transcription accuracy and productivity standards.

e. Demonstrate an awareness of the functions, operations, and dynamics of medical transcription work environments.

f. Demonstrate professionalism in the workplace.

g. Demonstrate an awareness of the opportunities in medical transcription and related careers and the importance of professional development.

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ETHICS AND CONFIDENTIALITY

Medical transcriptionists understand that the medical record is a legal document, and handling such sensitive information requires the utmost of professional ethics and confidentiality. Because of the confidential relationship between the physician and the patient, each medical record must remain absolutely confidential.

As a working MT you should never relay patient information to outside parties. It is very important to take the security of the patient record seriously. This means that even if you are transcribing your best friend's reports, the fact that you do so should never be discussed.

Most facilities and MTSOs (medical transcription service owners) require the transcriptionist to sign a confidentiality statement upon hiring, and violation of this is cause for termination and possibly legal recourse. Make it a practice to transcribe your reports, proof and edit them, and then forget about them. Most confidentiality has been broken because transcriptionists talk to their friends about an unusual problem she has encountered in a medical record. The problems that could occur with this are:

A. Somebody could overhear you, and that somebody could be a relative of the patient.

B. Your friend could know the patient in question and spread the news even further.

C. You portray a less than professional image when discussing contents of medical reports.

(Of course this does not include asking transcription-related questions.)

Ownership of the healthcare record belongs to the facility, but the patient is entitled to copies when a written request has been issued. Unless it is your job specifically, the medical transcriptionist should never make copies for the patient when requested directly by the patient or a family member. Remember, your job is to keep the records confidential at all times.

There are new guidelines concerning medical records in a set of laws called HIPAA (Health Insurance Portability and Accountability Act.) Parts of the HIPAA laws discuss the handling of medical records, and this could affect MTs that work at home. MTs who work at home are being encouraged to take measures to protect any information on their computers or on floppy disks. Some of these measures include password protecting your computer, keeping your virus definitions up to date, and locking any floppy disks that may contain confidential information in a file cabinet or box. It's also important not to let anyone have access to the part of your computer that contains vital patient information and diagnoses. One transcriptionist I know was haphazard about doing so, and her husband's boss's medical reports were discussed. This type of thing is in direct violation of HIPAA Federal laws and could have serious consequences. Therefore, always protect your information on your computer (and shred any trash with patient names) once you begin working on the job.

Many MT services are now using “encryption” to send/receive medical records through e-mail. Encryption is a process that uses special encryption software to protect the electronic transfer of medical records. One of the more popular types of encryption programs is Cryptext which is inexpensive and very easy to use. We will explore this software and more later in the course.

Electronic signatures are popular methods of signing medical reports by the dictating physicians. This means that the physician’s typed name on the report is sufficient instead of a physical signature. Electronic signatures, however, open the door for errors that would not be caught because the physician is not reading or signing the reports. Because of this, it is vitally important that the medical transcriptionist have a complete understanding of the dictation they are transcribing in order to ensure they are transcribing exactly as the doctor dictates. That's just another reason why a good MT course is important to your career!

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INDUSTRY TRENDS AND POTENTIAL THREATS

INDUSTRY TRENDS AND POTENTIAL THREATS

The most conceivable and recognizable threat to the medical industry as a whole is the emergence of new voice recognition software. However, in spite of the advances in this technology, it has been difficult for the computer to grasp and analyze the human voice and the English language with all its diversity. Besides, as many as software develop, there will still be people needed to edit what is transcribed by the software. Hence, there will continue to be a need for skilled medical language specialists who expand their education and have the knowledge to identify and edit the inevitable errors created by speech recognition systems and who have enough understanding of health records to create an accurate final document. Medical transcriptionists will therefore remain the ultimate qualified persons to discern the nuances of human speech.

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GYNAECOLOGY TRANSCRIPTION

Gynaecology Transcription

Eyered is a leading medical transcription service from India offering accurate overnight transcription of medical documents to practitioners in the United States. Our clients include healthcare facilities, hospitals, physicians' groups and individual doctors who send us voice recordings of their patient notes, medical records and correspondence to referring doctors. Our well qualified transcriptors convert these into accurate word files. They are trained for transcription in various medical fields including Gynecology transcription.

Take advantage of our extremely reasonable rates and the time difference between the United States and India. Your HIPAA compliant Gynecology transcription will be as good as STAT! Recordings sent by you in the evening will be transcribed, edited, checked by a gynecologist and the encrypted files returned to your office by the next morning. Ask for a seven day free trial today!

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CARDIOLOGY TRANSCRIPTION

Cardiology Transcription Services

With the prominence of cardiology in the field of medicine, cardiology transcription services also gained its power in the market. There are a variety of cardiological problems that require long-term treatment process. Thus the need of transcription becomes important for a hospital in order to maintain an accurate medical report of each patient. Outsource Strategies International (OSI), being a pioneer in medical transcription industry, stress on quality medical transcription services with quick turn around times. As we specialize in cardiology transcription, we can proudly say that we are among the best cardiology transcription providers in the US.

Our cardiology transcription services are availed by hospitals, clinics, doctors, and other medical groups throughout the country as well as abroad. OSI’s transcription services follow all the HIPAA regulations. We assure quality-driven transcription services thereby helping you save a lot of money and your time. In our cardiology transcription services, we also ensure confidentiality of your health information. We function as a member of your staff and work with your present dictation methods thereby supplying you the needed transcribed documents with prompt report turnaround. We can even suggest alternate technology to streamline your operation.

Our cardiology transcription services include making operative and emergency room reports, patient’s discharge summaries, physical reports, digital dictation services and many more. We use 256 bit AES encryption method and supports EMR interface capabilities. Quality and accuracy are the main standards which we concentrate while doing your cardiology transcription. With our highly experienced and dedicated cardiology transcription team, we can effectively transcribe notes that are associated with cardiac catheterizations, electrophysiology, echocardiograms, and treadmill tests.

Our medical transcription company offers cardiology transcription services at cost competitive rates with accuracy of over 99 % for standard transcription service. Once we finish your transcription process, the legal quality transcription reports are transmitted to you using secure encrypted e-mail or FTP. All our employees undergo security screening and HIPAA training. In addition to these, our cardiology transcription services also include your back office works as well.

We avail you an opportunity to evaluate our quality cardiology transcription services using our free trial offer. This helps you to give your transcription jobs to us after getting a clear idea about our services. For getting more information regarding our cardiology medical transcription, cardiology medical billing and coding services, contact us via email or call us.

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The Brilliant Future of Medical Transcription

Often when someone is interested in becoming a medical transcriptionist they are curious about what the future of medical transcription is going to be. They want to be sure, understandably, that there is a solid future awaiting them in this field.

Their main concern usually involves Speech (or Voice) Recognition Technology (SRT).

There are two main types of voice recognition: Front-end voice recognition and back-end voice recognition. In both cases the doctors are dictating into a microphone fed into a computer. The "microphone" could be their PDA (personal digital assistant), a telephone, or an actual microphone at a computer station. The computer then converts their spoken words into written words and stores them in an electronic document.

With front-end voice recognition, the doctor knows that this is being done and is able to see the report being transcribed by the computer. She can edit and sign the report without it being seen by an MT if she wants to have it processed that way (few do!). A second option is for her to be able look at the report but then have an MT edit it before she signs off on it.

With back-end voice recognition, the doctor often isn't aware the software is in place. It is invisible to him. He will speak into a microphone like he always has, never knowing that the computer is turning his spoken words into written ones. These reports are then sent to an MT for editing purposes and then they are returned to the doctor for his signature.

Software in this field is advancing rapidly, but for the most part it is still unable to handle the wide variety of doctors' accents combined with the extensive medical vocabulary they use. In addition, SRT does not correct typographical errors, nor can it catch dictation errors when, for example, the wrong dosage is dictated for a medication. Most hospitals and large transcription companies that use SRT have simply transitioned their medical transcriptionists over to being MT editors. This recently happened to me, and I have to say I really enjoy editing work! It is fast, it is interesting, it is varied, and there is always at least one good laugh each day. Today I really appreciated the software turning the patient's name into a medical condition. It was quite hilarious!

Many MTs actually would rather do editing work, as it can be much easier physically (especially on the wrists) to listen and correct a report than to listen and type every word spoken.

The wonderful news for the person investigating becoming a medical transcriptionist is that the training is still the same. You still need to know the basic medical terminology, pharmaceutical terms, and speed techniques, because they will all still be involved should you end up doing editing work rather than straight transcription. The other thing you should know is that it is very, very rare for anyone to ever do 100% editing work. Even the best back-end voice recognition software packages for physicians are only able to accurately transcribe 70% to 80% of the voices in any given system. A lot of doctors simply move around their text too much and are far too disorganized in their transcription style to even begin to allow SRT to create a semi-decent report!

In summary, the smart, educated, well-equipped medical transcriptionist rarely has a hard time finding a good position. The future of medical transcription is still very bright!

Susan Eliot is an expert in the field of medical transcription. She is an excellent resource when it comes to finding medical transcriptionist work. She owns and operates her own medical transcription company and knows first hand all the details about medical transcriptionist work.

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