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Medical Transcription

Medical transcription, also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals, into text format.

An individual who performs medical transcription is known as a medical transcriptionist or an MT. The equipment the MT uses is called a medical transcriber. The individual who performs medical transcription should always be called a “medical transcriptionist.” A medical transcriptionist is the person responsible for converting the patient’s medical records into text from recorded dictation. The term transcriber describes the electronic equipment used in performing medical transcription, e.g., a cassette player with foot controls operated by the MT for report playback and transcription. There have been industry discussions centered around whether or not medical transcriptionists should be called something else; no other industry-wide term has been adopted.

Education and training can be obtained through certificate or diploma programs, distance learning, and/or on-the-job training offered in some hospitals, although there are countries currently employing transcriptionists that require 18 months to 2 years of specialized MT training. Working in medical transcription leads to a mastery in medical terminology and editing, MT ability to listen and type simultaneously, utilization of playback controls on the transcriber (machine), and use of foot pedal to play and adjust dictations – all while maintaining a steady rhythm of execution.

While medical transcription does not mandate registration or certification, individual MTs may seek out registration/certification for personal or professional reasons. Obtaining a certificate from a medical transcription training program does not entitle an MT to use the title of Certified Medical Transcriptionist (CMT). The CMT credential is earned by passing a certification examination conducted solely by the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), as the credentialing designation they created. AHDI also offers the credential of Registered Medical Transcriptionist (RMT). According to AHDI, the RMT is an entry-level credential while the CMT is an advanced level. AHDI maintains a list of approved medical transcription schools.

There is a great degree of internal debate about which training program best prepares a MT for industry work[3]. Yet, whether one has learned medical transcription from an online course, community college, high school night course, or on-the-job training in a doctor’s office or hospital, a knowledgeable MT is highly valued. In lieu of these AHDI certification credentials, MTs who can consistently and accurately transcribe multiple document work-types and return reports within a reasonable turnaround-time (TAT) are sought after. TATs set by the service provider or agreed to by the transcriptionist should be reasonable but consistent with the need to return the document to the patient’s record in a timely manner.

As of March 7, 2006, the MT occupation became an eligible U.S. Department of Labor Apprenticeship, a 2-year program focusing on acute care facility (hospital) work. In May 2004, a pilot program for Vermont residents was initiated, with 737 applicants for only 20 classroom pilot-program openings. The objective was to train the applicants as MTs in a shorter time period. (See Vermont HITECH for pilot program established by the Federal Government Health and Human Services Commission).

Curricular requirements, skills and abilities

experience that is directly related to the duties and responsibilities specified, and dependent on the employer (working directly for a physician or in hospital facility).

  • Knowledge of medical terminology.
  • Above-average spelling, grammar, communication and memory skills.
  • Ability to sort, check, count, and verify numbers with accuracy.
  • Skill in the use and operation of basic office equipment/computer; eye/hand/foot coordination.
  • Ability to follow verbal and written instructions.
  • Records maintenance skills or ability.
  • Above-average to excellent typing skills.

Basic MT knowledge, skills and abilities

  • Knowledge of basic to advanced medical terminology is essential.
  • Knowledge of anatomy and physiology.
  • Knowledge of disease processes.
  • Knowledge of medical style and grammar.
  • Average verbal communication skills.
  • Above-average memory skills.
  • Ability to sort, check, count, and verify numbers with accuracy.
  • Demonstrated skill in the use and operation of basic office equipment/computer.
  • Ability to follow verbal and written instructions.
  • Records maintenance skills or ability.
  • Above-average typing skills.
  • Knowledge and experience transcribing (from training or real report work) in the Basic Four work types: History and Physical Exam, Consultation, Operative Report, and Discharge Summary.
  • Knowledge of and proper application of grammar.
  • Knowledge of and use of correct punctuation and capitalization rules.
  • Demonstrated MT proficiencies in multiple report types and multiple specialties.

Duties and responsibilities

  • Accurately transcribes the patient-identifying information such as name and Medical Record or Social Security Number.
  • Transcribes accurately, utilizing correct punctuation, grammar and spelling, and edits for inconsistencies.
  • Maintains/consults references for medical procedures and terminology.
  • Keeps a transcription log.
  • In some countries, MTs may sort, copy, prepare, assemble, and file records and charts (though in the United States (US) the filing of charts and records are most often assigned to Medical Records Techs in Hospitals or Secretaries in Doctor offices).
  • Distributes transcribed reports and collects dictation tapes.
  • Follows up on physicians’ missing and/or late dictation, returns printed or electronic report in a timely fashion (in US Hospital, MT Supervisor performs).
  • Performs quality assurance check.
  • May maintain disk and disk backup system (in US Hospital, MT Supervisor performs).
  • May order supplies and report equipment operational problems (In US, this task is most often done by Unit Secretaries, Office Secretaries, or Tech Support personnel).
  • May collect, tabulate, and generate reports on statistical data, as appropriate (in US, generally performed by MT Supervisor).

Source: http://en.wikipedia.org/wiki/Medical_transcription