Medical Transcription

Medical Transcription is the process of converting medical dictations (digital voice) to textual format (usually in a word document). The voice files usually contain the voice of medical professionals, mostly physicians or their assistants dictating for a physician. They dictate notes on patient encounters and the same is made available in a digital format which a professional medical transcriptionist listens to and types (transcribes). The purpose of medical transcription is primarily two fold. The transcribed document serves as a medical record which the physician needs to produce to the insurance company in order to have his claim approved. Secondly every document serves as a legal document and can be used as evidence in favor or against the physician in case of a medical negligence filed by the patient.

As far as skillsets needed for medical transcription, one has to undergo a training of 6-8 months where one is taught the basics of all body systems, medical terminology including disease names and medical equipments, surgical procedures, drug names, transcription rules, English grammar, spellings, and also some good typing skills. A medical transcriptionist is also familiar with the different types of medical reports like Procedure notes, discharge summaries, consultation reports and SOAP notes.

Medical Transcription Services include the act of transcribing medical reports that are dictated by physicians, nurses and other healthcare practitioners. Dictations are voice files typically called in over the telephone or uploaded digitally via the Internet and now through smart phone apps.

With today’s technology, there are numerous electronic devices that are used to record audio files such as a digital handheld recorder, iPhone App, or toll free call in voice servers. The provider then dictates office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries and uploads them to a transcriptionist who then types them.

Rahul Varshneya, Cofounder of medical software development company Arkenea says, “When choosing a transcription service for your facility, you should consider one that is compatible with your current electronic medical records (EMR) system if your practice has one. Many services offer EMR integration and free technical support so that transferring and filing patient records is easy.”

Physicians, nurses, or other healthcare providers dictate a note in digital audio format to keep track of a patient’s health, history and care. Dictations are then transcribed into a word document by medical transcriptionists and sent back to the physician electronically. Physicians will approve or make changes to their medical transcriptions before saving and storing to a patient’s medical record. Cardiologists, Pathologists, Radiologists, Surgeons, and a host of other medical specialists must all coordinate their efforts to ensure that patient care is adequate and appropriate.

Traditionally, professionally skilled medical transcriptionists working in the medical records department of a hospital accomplishes the transcribing of medical reports. However, medical transcription has changed over the years. Instead of an assortment of handwritten notes for the record, the approach has gone digital and healthcare organizations are shifting to electronic format. These patient reports are safely stored in the electronic database and are available for immediate access and retrieval anytime by permitted and affiliated healthcare personnel.

Today, many electronic health record systems have built-in voice recognition and dictation storage that can be adapted to many models of transcribing, including outsourcing or in-house solutions. But still time and experience have shown that online traditional medical transcription is still the most affordable and accurate, time saving solution. This holds true because physicians do not have the time to spend countless hours revising their notes. Most online medical transcription services companies have a methodology or process in place to perform the steps necessary to complete work successfully. The process for example may include these steps: submission and retrieval, transcribing, quality assurance, report delivery and file storage and archival.

Turn-around time (TAT) is defined as the time it takes to receive finished reports after submission of dictation files. For medical transcription services, TAT can vary from 2, 4, 8, 12, 24 or 48 hours where standard TAT is typically 12 to 24 hours. Should a physician need a report sooner than the regular TAT it is termed STAT, another term used to imply urgent or rush delivery.

Medical transcriptionist’s convert dictated audio files to transcribed medical transcription reports. They not only transcribe voice files, but they also edit and properly format reports and then safely return them in either printed or electronic format for physician review and sign off or to make updates if necessary. Medical transcriptionists are skilled in medical terminology and act in compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements. Medical transcription is performed in many various ways. It can be performed by in-house transcriptionists who are employees at a hospital or contractor who work from home. There are several certification classes and online training available for candidates interested in pursuing a career as a medical transcriptionist. The outlook looks good and the employment of medical transcriptionists is projected to grow by 11% from 2008 to 2018 in the US.

The medical transcription profession has existed for several decades primarily in the US, and other western countries and the services had begun to be outsourced to some Asian countries like India, Philippines, and Pakistan around the late 90s. The profession is now on a declining phase due to a number of changes in the healthcare industry which have quite significantly impacted the profession. The emergence of new technologies like Voice Recognition where a software program can convert a voice into text has significantly reduced the need for medical transcriptionists over the years. Also the emergence of EMR (Electronic Medical Record) has played its role in reducing the need for manual transcription.