In short, medical transcription is the process by which a trained professional listens to spoken recordings that a physician or other health care worker makes and transcribes them into readable documents, such as medical reports, correspondence and other administrative material. Medical transcription also produces other vital documents of record, such as patient discharge summaries, medical histories, reports of physical exams, operative reports, autopsy reports, diagnostic imaging studies, consultation reports, notes a physician makes on a patient’s progress and even referral letters.
Usually how the transcription process works is a medical transcriptionist will listen to the recordings given to them on a headset, using a pedal at their feet to pause the recording when needed. They then type in the words into a computer or word processor. Editing for grammar and clarity is also an essential part of medical transcription. When the medical transcription is complete, the transcriptionist gives the documents he or she produces back to the physician or other party who dictated them, so that that party can look over the finished product and either sign it or send it back for correction. Accuracy and quality work in this field are important because these transcribed documents eventually become a part of patients’ permanent medical files. Physicians refer to and depend on these files to help them form diagnoses or establish a treatment plan to help the patient.
Medical transcription entails a greater understanding of medicine than it might seem. To be able to make sense out of these recordings in writing, a medical transcriptionist needs to understand medical terminology and jargon, anatomy & physiology, diagnostic procedures, pharmacology and treatment assessments, according to the U.S. Bureau of Labor Statistics. Medical transcription entails “translating” jargon into its accurate, expanded and more technical names for official medical records. Many medical transcriptionists refer to various medical reference materials to effectively do their job.
Specific legal standards apply for medical transcription and the transcriptionist needs to meet both those standards and obey “house rules” when it comes to transcription—meaning, typing the information out the way a doctor prefers it to be recorded. By law, maintaining the confidentiality of these transcribed records is also crucial.
A good medical transcriptionist keeps an eagle eye out for mistakes or inconsistencies in a spoken report and checks with a physician to correct or clarify information. This means medical transcription plays a key role in reducing human error, leading to higher-quality medical care.