Healthcare and Medical Transcription

Health care today consists of many diverse specialties and subspecialties. One that is rarely known or spoken of in general is Medical Transcription. It is often confused with medical records and general dictation, but Medical Transcription is a specialty in a class of its own. Of all the medical branches that the general public has knowledge of, Medical Transcription shows as a big blank in most of our minds. Most MT departments are located within the Health Information Management section of a hospital or clinic, but some are located outside of medical facilities and are a business that is outsourced to private physicians. This particular unit of the medical profession is an essential part of the medical field, and its uses and benefits are constantly increasing the need and demand for it in today’s society.

Now perhaps you are wondering just what exactly Medical Transcription is and how it all works for you. Technically defined, Medical transcription is the process whereby one accurately and swiftly transcribes medical records dictated by doctors and others, including history and physical reports, clinic notes, office notes, operative reports, consultation notes, discharge summaries, letters, psychiatric evaluations, laboratory reports, x-ray reports and pathology reports. It involves receiving dictation by tape, digital system or voice file, and using ear phones, a foot pedal for start-stop control and a word processing program. It requires good listening and language skills, computer skills and knowledge of medical terms. On the other hand, in every day conversation, its definition would simply be the typing out of all things said by the doctor and/or patient during an office visit or procedure on any given day. It keeps all records in a hospital, clinic, or doctor’s office up-to-date, and without it, there would be much chaos in these institutions. MT has a history that goes back as far as Ancient times, and the proof is from Ancient writings on the walls of caves that go back as far as 1500 B.C. For thousands of years, the physician treated the patient and wrote an occurrence of all that took place during the visit. It was time consuming and confusing, because the physician had to wait until the end of the day to write down

everything that had taken place with every patient. There were many inaccuracies, and there were many times when records were written for the wrong person. As time passed, especially during the early 1900s, physicians no longer had time to practice both medicine and write all incidents that occurred during a visit with a patient. This is where MT came into play. It was accepted world-wide in 1978 as a major factor in the medical profession, and physicians have come to depend on it just as much as a patient depends on his/her physician. Now that I have told you a little about MT, let me give you an example of how it works.

Just for the sake of argument, suppose you were rushed to the hospital for severe chest pains. Once you reached the emergency room, the doctor ordered the nurse to

perform several tests that consisted of EKG, LFT, BUN, UA to rule out a possible MI.. All tests were performed, and it was determined that all you had was a severe case of GERD. Two weeks later, you request a copy of your records from that visit, and when you look at them, you feel a little better knowing that you have a hard copy to refer to whenever you please. Have you ever wondered who typed out that piece of paper you are looking at, or who took the time and effort to make it possible for you to be able to even obtain a copy of it? The answer is simple; it was a Medical Transcriptionist. This person is trained to do the job right, and there is no margin for error. An MT must be extensively trained in medical terminology, medical dictation, anatomy and physiology, accounting, word processing, medical abbreviations, and many other subjects that are medically and business related. An MT professional has a broad knowledge of business office technology along with over 60 medical specialties. He/she must learn to understand many different dialects spoken by different physicians, and he/she must be able to recognize and question when the physician makes a mistake in a diagnosis. He/she must complete at least 65 hours of training in an institutional setting,

and have at least 240 hours of on-the-job training with a supervisor before trying to work alone in the office or at home. All information that is dictated to the MT is confidential,

and he/she is not able to discuss those dictations with anyone other than the physician or his/her immediate supervisor. Any breach of confidentiality is immediate grounds for dismissal, and possible legal action.

MTs are in high demand, and the job market is the best that it has ever been. Starting