The free encyclopediaMedical 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 or other healthcare professionals, into text format.
History
Evolution of transcription dates back to the 1960s. The method was designed to assist in the manufacturing process. The first transcription that was developed in this process was MRP, which is the acronym for Manufacturing Resource Planning, in 1975. This was followed by another advanced version namely MRP2. But none of them yielded the benefit of medical transcription. However, transcription equipment has changed from manual typewriters to electric typewriters to word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings.
Today, speech recognition (SR), also known as continuous speech recognition (CSR), is increasingly being used, with medical transcriptionists and or "editors" providing supplemental editorial services, although there are occasional instances where SR fully replaces the MT. Natural-language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide (although MTs do). In the past, these medical reports consisted of very abbreviated handwritten notes that were added in the patient's file for interpretation by the primary physician responsible for the treatment. Ultimately, this mess of handwritten notes and typed reports were 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.
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. In recent years, medical records have changed considerably. Although many physicians and hospitals still maintain paper records, there is a drive for electronic records. Filing cabinets are giving way to desktop computers connected to powerful servers, where patient records are processed and archived digitally. This digital format allows for immediate remote access by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises. Many MTs now utilize personal computers with electronic references and use the Internet not only for web resources but also as a working platform.
Technology has gotten so sophisticated that MT services and MT departments work closely with programmers and information systems (IS) staff to stream in voice and accomplish seamless data transfers through network interfaces. In fact, many healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants (PDAs) and are now utilizing software on them An individual who performs medical transcription is known as a medical transcriptionist (MT) or a Medical Language Specialist (MLS). The equipment used is called a medical transcriber, e.g., a cassette player with foot controls operated by the MT for report playback and transcription. 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, 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 an MT for industry work. 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. While most medical transcription agencies prefer candidates with a minimum of one year experience, formal instruction is not a requirement, and there is no mandatory test. Some hospitals require nothing more than a diploma for employment as a medical transcriptionist. The average pay range for an in-house MT in a hospital setting is $8/hr.
On 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
•Sound Knowledge of basic to advanced medical terminology is essential.•Sound Knowledge of anatomy and physiology.
•Sound Knowledge of disease processes. •Sound Knowledge of medical style and grammar.
•Effective 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).
The medical transcription process
When the patient visits a doctor, the latter spends time with the former discussing his medical problems, including history and/or problems. The doctor performs a physical examination and may request various laboratory or diagnostic studies; will make a diagnosis or differential diagnoses, then decides on a plan of treatment for the patient, which is discussed and explained to the patient, with instructions provided. After the patient leaves the office, the doctor uses a voice-recording device to record the information about the patient encounter. This information may be recorded into a hand-held cassette recorder or into a regular telephone, dialed into a central server located in the hospital or transcription service office, which will 'hold' the report for the transcriptionist. This report is then accessed by a medical transcriptionist, it is clearly received as a voice file or cassette recording, who then listens to the dictation and transcribes it into the required format for the medical record, and of which this medical record is considered a legal document. The next time the patient visits the doctor, the doctor will call for the medical record or the patient's entire chart, which will contain all reports from previous encounters.
The doctor can on occasion refill the patient's medications after seeing only the medical record, although doctors prefer to not refill prescriptions without seeing the patient to establish if anything has changed. It is very important to have a properly formatted, edited, and reviewed medical transcription document. If a medical transcriptionist accidentally typed a wrong medication or the wrong diagnosis, the patient could be at risk if the doctor (or his designee) did not review the document for accuracy. Both the doctor and the medical transcriptionist play an important role to make sure the transcribed dictation is correct and accurate. The doctor should speak slowly and concisely, especially when dictating medications or details of diseases and conditions.
The medical transcriptionist must possess hearing acuity, medical knowledge, and good reading comprehension in addition to checking references when in doubt. However, some doctors do not review their transcribed reports for accuracy, and the computer attaches an electronic signature with the disclaimer that a report is "dictated but not read". This electronic signature is readily acceptable in a legal sense. The transcriptionist is bound to transcribe verbatim (exactly what is said) and make no changes, but has the option to flag any report inconsistencies. On some occasions, the doctors do not speak clearly, or voice files are garbled. Some doctors are, unfortunately, time-challenged and need to dictate their reports quickly (as in ER Reports).
In addition, there are many regional or national accents and (mis)pronunciations of words the MT must contend with. It is imperative and a large part of the job of the Transcriptionist to look up the correct spelling of complex medical terms, medications, obvious dosage or dictation errors, and when in doubt should "flag" a report. A "flag" on a report requires the dictator (or his designee) to fill in a blank on a finished report, which has been returned to him, before it is considered complete. Transcriptionists are never, ever permitted to guess, or 'just put in anything' in a report transcription. Furthermore, medicine is constantly changing. New equipment, new medical devices, and new medications come on the market on a daily basis, and the Medical Transcriptionist needs to be creative and to tenaciously research (quickly) to find these new words. An MT needs to have access to, or keep on memory, an up-to-date library to quickly facilitate the insertion of a correctly spelled device.
Outsourcing of medical transcription
Due to the increasing demand to document medical records, countries have started to outsource the services of medical transcription. In the United States, the medical transcription business is estimated to be worth US$10 to $25 billion annually and growing 15 percent each year.[6] The main reason for outsourcing is stated to be the cost advantage due to cheap labor in developing countries, and their currency rates as compared to the U.S. dollar. Drivers that Influence Outsourcing to Medical Transcription Partners.
