Medical Transcription: Everything You Need to Know and More
November 2020
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3 min read
Healthcare professionals already have a busy and stressful job. On top of that, they need to spend hours creating medical records. This not only limits patient care but is tedious and time-consuming.
Some healthcare professionals hire assistants to transcribe their notes. Even with the extra help, they experience delays and inaccuracies. Trained and experienced medical transcribers are difficult to find and expensive to hire.
Errors in medical notes can compromise a patient's health and expose the hospital to malpractice lawsuits.
That's why we've compiled this comprehensive guide about medical transcription.
What is medical transcription?
Medical transcription is creating a written record of the words spoken by doctors. It can also include notes from nurses and other healthcare professionals involved in patient care.
What is the result of medical transcription?
Hospitals create lots of reports at different stages of patient care. Some examples are:
- Consultation report includes the patient's assessment report and treatment plan.
- History and Physical report include the patient's current illness and medical history.
- Operative report includes pre and post-operative notes, the type of operation, the surgeon's and anesthesiologist's names, and a thorough explanation of the actual surgical procedure.
- Lab report contains the analysis of laboratory test results and further instructions.
- Radiology report is the analysis of nuclear medicine tests, X-rays, MRIs, CT scans, and other imaging techniques.
- Hospital report is a running compilation of all the patient's reports.
- Discharge summary compiles all the reports generated from the patient's admission to discharge. If the patient is being transferred to another institution, we call it a transfer summary. If the patient passes away, the same document is called a death summary.
- Office reports include internal documents like initial evaluations, letters to referring physicians, patient introduction letters to specialists, and chart notes for each visit.
What do medical transcriptionists do?
A medical transcriptionist types a doctor's spoken words during a visit to record the patient's health history.
They pause and seek clarification if they come across contradictory information. For instance, they will re-check to ensure the record is true when someone says they are taking a drug they are allergic to.
Duties and Responsibilities of a medical transcriptionist include:
- Transcription of patient data, including name, social security number, and medical history
- Examining the sources for medical terminology and medical procedures
- Accurate transcription and correcting errors
- Preserving a log of transcriptions
- Following up on doctors' dictation and sending reports back
How to become a medical transcriptionist?
At a minimum, a medical transcriber must have a high school diploma or GED. Needless to say, you need to be a good listener and a touch typist.
You also need previous experience with non-medical transcription and HIPAA compliance training.
What is the benefit of medical transcription?
Medical transcription allows the sharing of information among medical workers so that everyone is on the same page.
It is quicker to skim through a written document than listening to an audio recording, as it saves crucial time for healthcare workers.
Should you outsource your medical transcription?
Mistakes in medical transcription can put patients' health in jeopardy. Doctors can lose their medical licenses over incorrect records. It's natural to be hesitant about outsourcing this critical work.
A professional medical transcription company understands the importance of accurate transcripts. Besides transcribing, they also edit and format transcripts as per your request and ensure data security.
Things to consider while choosing a medical transcription service
- Cost: Most medical transcription companies charge based on per minute of audio. You can calculate the estimated cost on that basis.
- Experience: You don't want your transcription provider to learn at your expense. Choose one that has previous experience in the medical domain.
- Accuracy: Select a medical transcription provider that guarantees an accuracy of at least 98 percent. The accuracy rate will also depend on how many people proofread the transcript.
- HIPAA compliance: Medical transcription contains patients' confidential health information. A HIPAA-compliant company will ensure the security of both Protected Health Information (PHI) & ePHI.
Medical transcription by Reduct
Our transcribers are skilled and knowledgeable in the field of medical transcription. We deliver accurate transcripts within a short turnaround time so that you can focus on providing the best care for patients.
