Medical Transcription (Medical Records)
Content
Medical Transcription
What is Medical
Transcription?
• The process of converting voice
dictation into a permanent written
record utilizing word processing
equipment and software.
• Each day in hospitals, thousands of
patients are admitted and
discharged.
– Examinations are conducted,
procedures are performed and
recommendations are made.
What is Medical
Transcription?
• Each patient-related activity and
procedure must be meticulously
documented and then added to the
patient's permanent record.
• Physicians and medical record handlers
alike must be extremely careful to
ensure that detailed patient
identification information accompanies
each procedure and examination report
to avert potentially disastrous mix-ups.
What is Medical
Transcription?
• Over time, all of this
information accumulates in a
centralized medical records
repository where it serves as a
critical resource for patient care
- facilitating accurate diagnoses
and appropriate treatments.
Transcription Process
Computer/Serv
er
Server
US MD
MD asst.
FTP or TASP
VoIP
1800
MTs
Evolution and History
• The father of modern medicine,
Hippocrates, had physician
notes as a written record of
medical actions and also
served as a basic guide for
reference for future patient
care.
Evolution and History
• In the past, these reportings consisted
of very abbreviated handwritten notes
that were funneled into the patient's file
for interpretation by the primary
physician responsible for diagnosing
ailments and prescribing treatment.
• Ultimately, consolidated into a single
patient file and physically stored along
with thousands of other patient records
in a wall of filing cabinets in the medical
records department.
Evolution and History
• Whenever the need arose to review
the records of a specific patient, the
patient's file would be retrieved
from the filing cabinet and delivered
to the requesting physician.
• To enhance this manual process,
many medical record documents
were produced in duplicate or
triplicate by means of carbon copy.
Evolution and History
• In the early 1900s, medical
stenographers began taking dictation by
shorthand; thereafter, dictation
machines evolved.
• Virtually every visit to the doctor, every
admission to the hospital, requires a
comprehensive record of the encounter,
including the diagnosis, treatment, and
outcome. This is the material
transcribed by the MT.
Evolution and History
• In the 1960s, the job title was
medical secretary, the keyboard was
a manual typewriter, the dictation
was recorded on magnetic belts or
plastic grooved disks, the standard
reference was a Taber’s dictionary,
and transcription was done only
within healthcare facilities.
Evolution and History
• Physicians came to rely on the judgment
and reasoning of experienced medical
secretaries to safeguard the accuracy
and integrity of medical dictation,
leading to medical transcription evolving
into a medical language specialty.
• Medical transcription is one of the most
sophisticated of the allied health
professions, creating an important
partnership between healthcare
providers and those who document
patient care
Evolution and History
• In recent years things have
changed considerably. Walls of
filing cabinets have given way to
desktop computers connected to
powerful mainframe systems
where patient records are
prepared and archived digitally.
Evolution and History
• In recent years things have
changed considerably. Walls of
filing cabinets have given way to
desktop computers connected to
powerful mainframe systems
where patient records are
prepared and archived digitally.
Evolution and History
• This digital format allows for
immediate remote retrieval by any
physician who is authorized to
review the patient information.
• Reports are stored electronically and
printed selectively as the need
arises.
Evolution and History
• While the transition from a paper
based to an electronic format will
take years to complete,
considerable progress has been
made.
• Handwritten reports are largely a
thing of the past.
• Verbal dictation is now by far the
most common method for
documenting and reporting the
results of examinations and
procedures.
Evolution and History
• Physicians generally use either a
cassette based voice dictation
system or a digital voice dictation
system to record their findings.
• Dictating reports verbally not only
allows physicians to be more
thorough in their reporting, it also
saves them a great deal of time.
Why Medical Transcription?
• It flows from the need for
documentation of medical records
and the inability of hard-pressed
doctors to sit and write those
reports themselves.
Why Medical Transcription?
– medical insurance claims and lawsuits
are decided on the documented case
history makes this all the more
necessary.
– doctors are frequently invited to
deliver lectures at medical colleges
implying the need to prepare
extensive notes on case studies to
be handed out to participating
students.
Reports transcribed
– Medical records dictated by doctors or
medical professionals
– History & physical reports
– Clinic notes
– Office notes
– Operative reports
– Consultation notes
– Discharge summaries
– Psychiatric evaluations
– Laboratory reports
– X-ray reports
– Pathology reports
Why Medical Transcription?
• The boom in transcription over the
past forty years is primarily due to
reimbursement demands.
– First diagnosis-related groups (DRGs)
and then Medicare and Medicaid, and
finally, all reimbursement systems have
demanded that diagnosis and
procedure codes for reimbursement be
substantiated by legible patient care
documentation.
– Transcribed notes provide that legibility.
– This improvement over handwritten
notes contributed to increased
documentation by dictation and
transcription.
Why Medical Transcription?
• As healthcare facilities felt increasing
pressures related to reimbursement,
they in turn faced increasing demands
on their resources – personnel, space,
and equipment.
• Costs for transcription increased, and
the appeal to turn over this
demanding task to outside businesses
became more and more attractive.
• These stimuli created big business,
and medical transcription became an
industry unto itself.
Why Medical Transcription?
• The Modern Healthcare Team
– Physicians
– Nurses
– Pharmacists
– Therapists
– Dietitians
– Technicians
– Medical Technologist
– Healthcare information manager
– Healthcare Educators
– MEDICAL TRANSCRIPTIONISTS
Qualities of a Medical
Transcriptionist
• What does a medical
transcriptionists need to know?
– practical knowledge of medical language,
anatomy, physiology, disease processes,
pharmacology, laboratory medicine
– internal organization of medical reports
– aware of standards and requirements that
apply to the health record
– legal significance of medical transcripts
Qualities of a Medical
Transcriptionist
• What are the characteristics of a Medical
Transcriptionist?
– The primary skills necessary for
performance of quality medical
transcription:
• extensive medical knowledge and
understanding
• above-average knowledge of English
punctuation and grammar
• excellent auditory skills
• versatility in use of transcription
equipment and computers
Qualities of a Medical
Transcriptionist
• What are the characteristics of a Medical
Transcriptionist?
– The primary skills necessary for
performance of quality medical
transcription:
• advanced proofreading and editing skills,
ensuring accuracy of transcribed material
• sound judgment and the ability to detect
medical inconsistencies in the medical report
• highly developed analytical skills, employing
deductive reasoning to convert sounds into
meaningful form
• Knowledge, Skills and Abilities
Required
Qualities of a Medical
Transcriptionist
– Knowledge of medical terminology
– Transcription skills.
– Ability to sort, check, count, and verify
numbers.
– Skill in the use of operating basic office
equipment.
– Ability to follow routine verbal and
written instructions.
– Ability to document work in progress.
– Records maintenance skills.
Qualities of a Medical
Transcriptionist
• Where are medical transcriptionists
employed?
1. healthcare settings
•
•
•
•
•
•
•
•
•
•
•
doctors' offices
public and private hospitals
teaching hospitals
medical transcription businesses
clinics, laboratories, radiology and pathology
departments
insurance companies
medical libraries
government medical facilities, rehabilitation
centers
legal offices, research centers
veterinary medical facilities
associations representing the healthcare
industry.
Qualities of a Medical
Transcriptionist
• Where are medical transcriptionists
employed?
2. work with physicians and surgeons in
multiple specialties, pharmacists,
therapists, technicians, nurses, dietitian,
social workers, psychologists, and other
medical personnel.
3. work at home as employees of
transcription businesses or hospitals as
independent contractors.
Qualities of a Medical
Transcriptionist
• Where are medical transcriptionists
employed?
4. may become quality assurance specialists,
supervisors, managers, department heads,
or owners of medical transcription
businesses.
5. Experienced medical transcriptionists may
become teachers, working in schools and
colleges to educate future medical
transcriptionists.
Requirements for job application
• Graduates of Nursing, Medical
Technology, Physical Therapy,
oth#er allied health courses, or a
medical transcription course from a
reputable transcription school.
• With at least 1 year experience in
Medical Transcription and 6 months
in editing OR 2 years transcription
experience.
• Must be able to produce off edit
work to a level of 98% accuracy.
Requirements for job application
• Must be able to edit a minimum of
1,000 lines per day.
• Excellent hearing acuity and
listening skills.
• Knowledgeable in basic computer
operations and internet applications.
• Must possess excellent English
communication skills, oral and
written. Willing to work a 44 hour
work week schedule.
• Willing to be assigned to any
schedule.
What is Medical
Transcription?
• The process of converting voice
dictation into a permanent written
record utilizing word processing
equipment and software.
• Each day in hospitals, thousands of
patients are admitted and
discharged.
– Examinations are conducted,
procedures are performed and
recommendations are made.
What is Medical
Transcription?
• Each patient-related activity and
procedure must be meticulously
documented and then added to the
patient's permanent record.
• Physicians and medical record handlers
alike must be extremely careful to
ensure that detailed patient
identification information accompanies
each procedure and examination report
to avert potentially disastrous mix-ups.
What is Medical
Transcription?
• Over time, all of this
information accumulates in a
centralized medical records
repository where it serves as a
critical resource for patient care
- facilitating accurate diagnoses
and appropriate treatments.
Transcription Process
Computer/Serv
er
Server
US MD
MD asst.
FTP or TASP
VoIP
1800
MTs
Evolution and History
• The father of modern medicine,
Hippocrates, had physician
notes as a written record of
medical actions and also
served as a basic guide for
reference for future patient
care.
Evolution and History
• In the past, these reportings consisted
of very abbreviated handwritten notes
that were funneled into the patient's file
for interpretation by the primary
physician responsible for diagnosing
ailments and prescribing treatment.
• Ultimately, consolidated into a single
patient file and physically stored along
with thousands of other patient records
in a wall of filing cabinets in the medical
records department.
Evolution and History
• Whenever the need arose to review
the records of a specific patient, the
patient's file would be retrieved
from the filing cabinet and delivered
to the requesting physician.
• To enhance this manual process,
many medical record documents
were produced in duplicate or
triplicate by means of carbon copy.
Evolution and History
• In the early 1900s, medical
stenographers began taking dictation by
shorthand; thereafter, dictation
machines evolved.
• Virtually every visit to the doctor, every
admission to the hospital, requires a
comprehensive record of the encounter,
including the diagnosis, treatment, and
outcome. This is the material
transcribed by the MT.
Evolution and History
• In the 1960s, the job title was
medical secretary, the keyboard was
a manual typewriter, the dictation
was recorded on magnetic belts or
plastic grooved disks, the standard
reference was a Taber’s dictionary,
and transcription was done only
within healthcare facilities.
Evolution and History
• Physicians came to rely on the judgment
and reasoning of experienced medical
secretaries to safeguard the accuracy
and integrity of medical dictation,
leading to medical transcription evolving
into a medical language specialty.
• Medical transcription is one of the most
sophisticated of the allied health
professions, creating an important
partnership between healthcare
providers and those who document
patient care
Evolution and History
• In recent years things have
changed considerably. Walls of
filing cabinets have given way to
desktop computers connected to
powerful mainframe systems
where patient records are
prepared and archived digitally.
Evolution and History
• In recent years things have
changed considerably. Walls of
filing cabinets have given way to
desktop computers connected to
powerful mainframe systems
where patient records are
prepared and archived digitally.
Evolution and History
• This digital format allows for
immediate remote retrieval by any
physician who is authorized to
review the patient information.
• Reports are stored electronically and
printed selectively as the need
arises.
Evolution and History
• While the transition from a paper
based to an electronic format will
take years to complete,
considerable progress has been
made.
• Handwritten reports are largely a
thing of the past.
• Verbal dictation is now by far the
most common method for
documenting and reporting the
results of examinations and
procedures.
Evolution and History
• Physicians generally use either a
cassette based voice dictation
system or a digital voice dictation
system to record their findings.
• Dictating reports verbally not only
allows physicians to be more
thorough in their reporting, it also
saves them a great deal of time.
Why Medical Transcription?
• It flows from the need for
documentation of medical records
and the inability of hard-pressed
doctors to sit and write those
reports themselves.
Why Medical Transcription?
– medical insurance claims and lawsuits
are decided on the documented case
history makes this all the more
necessary.
– doctors are frequently invited to
deliver lectures at medical colleges
implying the need to prepare
extensive notes on case studies to
be handed out to participating
students.
Reports transcribed
– Medical records dictated by doctors or
medical professionals
– History & physical reports
– Clinic notes
– Office notes
– Operative reports
– Consultation notes
– Discharge summaries
– Psychiatric evaluations
– Laboratory reports
– X-ray reports
– Pathology reports
Why Medical Transcription?
• The boom in transcription over the
past forty years is primarily due to
reimbursement demands.
– First diagnosis-related groups (DRGs)
and then Medicare and Medicaid, and
finally, all reimbursement systems have
demanded that diagnosis and
procedure codes for reimbursement be
substantiated by legible patient care
documentation.
– Transcribed notes provide that legibility.
– This improvement over handwritten
notes contributed to increased
documentation by dictation and
transcription.
Why Medical Transcription?
• As healthcare facilities felt increasing
pressures related to reimbursement,
they in turn faced increasing demands
on their resources – personnel, space,
and equipment.
• Costs for transcription increased, and
the appeal to turn over this
demanding task to outside businesses
became more and more attractive.
• These stimuli created big business,
and medical transcription became an
industry unto itself.
Why Medical Transcription?
• The Modern Healthcare Team
– Physicians
– Nurses
– Pharmacists
– Therapists
– Dietitians
– Technicians
– Medical Technologist
– Healthcare information manager
– Healthcare Educators
– MEDICAL TRANSCRIPTIONISTS
Qualities of a Medical
Transcriptionist
• What does a medical
transcriptionists need to know?
– practical knowledge of medical language,
anatomy, physiology, disease processes,
pharmacology, laboratory medicine
– internal organization of medical reports
– aware of standards and requirements that
apply to the health record
– legal significance of medical transcripts
Qualities of a Medical
Transcriptionist
• What are the characteristics of a Medical
Transcriptionist?
– The primary skills necessary for
performance of quality medical
transcription:
• extensive medical knowledge and
understanding
• above-average knowledge of English
punctuation and grammar
• excellent auditory skills
• versatility in use of transcription
equipment and computers
Qualities of a Medical
Transcriptionist
• What are the characteristics of a Medical
Transcriptionist?
– The primary skills necessary for
performance of quality medical
transcription:
• advanced proofreading and editing skills,
ensuring accuracy of transcribed material
• sound judgment and the ability to detect
medical inconsistencies in the medical report
• highly developed analytical skills, employing
deductive reasoning to convert sounds into
meaningful form
• Knowledge, Skills and Abilities
Required
Qualities of a Medical
Transcriptionist
– Knowledge of medical terminology
– Transcription skills.
– Ability to sort, check, count, and verify
numbers.
– Skill in the use of operating basic office
equipment.
– Ability to follow routine verbal and
written instructions.
– Ability to document work in progress.
– Records maintenance skills.
Qualities of a Medical
Transcriptionist
• Where are medical transcriptionists
employed?
1. healthcare settings
•
•
•
•
•
•
•
•
•
•
•
doctors' offices
public and private hospitals
teaching hospitals
medical transcription businesses
clinics, laboratories, radiology and pathology
departments
insurance companies
medical libraries
government medical facilities, rehabilitation
centers
legal offices, research centers
veterinary medical facilities
associations representing the healthcare
industry.
Qualities of a Medical
Transcriptionist
• Where are medical transcriptionists
employed?
2. work with physicians and surgeons in
multiple specialties, pharmacists,
therapists, technicians, nurses, dietitian,
social workers, psychologists, and other
medical personnel.
3. work at home as employees of
transcription businesses or hospitals as
independent contractors.
Qualities of a Medical
Transcriptionist
• Where are medical transcriptionists
employed?
4. may become quality assurance specialists,
supervisors, managers, department heads,
or owners of medical transcription
businesses.
5. Experienced medical transcriptionists may
become teachers, working in schools and
colleges to educate future medical
transcriptionists.
Requirements for job application
• Graduates of Nursing, Medical
Technology, Physical Therapy,
oth#er allied health courses, or a
medical transcription course from a
reputable transcription school.
• With at least 1 year experience in
Medical Transcription and 6 months
in editing OR 2 years transcription
experience.
• Must be able to produce off edit
work to a level of 98% accuracy.
Requirements for job application
• Must be able to edit a minimum of
1,000 lines per day.
• Excellent hearing acuity and
listening skills.
• Knowledgeable in basic computer
operations and internet applications.
• Must possess excellent English
communication skills, oral and
written. Willing to work a 44 hour
work week schedule.
• Willing to be assigned to any
schedule.
