Medical transcriptionists listen to dictated recordings made by physicians and other healthcare professionals and transcribe them into medical reports, correspondence, and other administrative material. They generally listen to recordings on a headset, using a foot pedal to pause the recording when necessary, and key the text into a personal computer or word processor, editing as necessary for grammar and clarity. The documents they produce include discharge summaries, history and physical examination reports, operative reports, consultation reports, autopsy reports, diagnostic imaging studies, progress notes, and referral letters. Medical transcriptionists return transcribed documents to the physicians or other healthcare professionals who dictated them for review and signature, or correction. These documents eventually become part of patients’ permanent files.
To understand and accurately transcribe dictated reports into a format that is clear and comprehensible for the reader, medical transcriptionists must understand medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. They also must be able to translate medical jargon and abbreviations into their expanded forms. To help identify terms appropriately, transcriptionists refer to standard medical reference materials—both printed and electronic; some of these are available over the Internet. Medical transcriptionists must comply with specific standards that apply to the style of medical records, in addition to the legal and ethical requirements involved with keeping patient information confidential.
Experienced transcriptionists spot mistakes or inconsistencies in a medical report and check to correct the information. Their ability to understand and correctly transcribe patient assessments and treatments reduces the chance of patients receiving ineffective or even harmful treatments and ensures high quality patient care.
Currently, most healthcare providers transmit dictation to medical transcriptionists using either digital or analog dictating equipment. The Internet has grown to be a popular mode for transmitting documentation. Many transcriptionists receive dictation over the Internet and are able to quickly return transcribed documents to clients for approval. Another emerging trend is the implementation of speech recognition technology, which electronically translates sound into text and creates drafts of reports. Reports are then formatted; edited for mistakes in translation, punctuation, or grammar; and checked for consistency and possible medical errors. Transcriptionists working in areas with standardized terminology, such as radiology or pathology, are more likely to encounter speech recognition technology. However, use of speech recognition technology will become more widespread as the technology becomes more sophisticated.
Medical transcriptionists who work in physicians’ offices and clinics may have other office duties, such as receiving patients, scheduling appointments, answering the telephone, and handling incoming and outgoing mail. Medical secretaries, discussed in the statement on secretaries and administrative assistants
elsewhere in the Handbook, may also transcribe as part of their jobs. Court reporters
, also discussed elsewhere in the Handbook, have similar duties, but with a different focus. They take verbatim reports of speeches, conversations, legal proceedings, meetings, and other events when written accounts of spoken words are necessary for correspondence, records, or legal proof.