John Michael Bolaos February 23, 2016

BSMT 3I

Medical transcription,

Is also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-
recorded reports as dictated byphysicians or other healthcare professionals, into text format.

Over view description

Medical transcription is part of the healthcare industry that renders and edits doctor dictated reports, procedures, and
notes in an electronic format in order to create files representing the treatment history of patients. Health
practitioners dictate what they have done after performing procedures on patients and MTs transcribe the oral
dictation and/or edit reports that have gone through speech recognition software.[5]

Pertinent up-to-date, confidential patient information is converted to a written text document by a medical
transcriptionist (MT).[6] This text may be printed and placed in the patient's record and/or retained only in its
electronic format. Medical transcription can be performed by MTs who are employees in a hospital or who work at
home as telecommuting employees for the hospital; by MTs working as telecommuting employees or independent
contractors for an outsourced service that performs the work offsite under contract to a hospital, clinic, physician
group or other healthcare provider; or by MTs working directly for the providers of service (doctors or their group
practices) either onsite or telecommuting as employees or contractors. Hospital facilities often prefer electronic
storage of medical records due to the sheer volume of hospital patients and the accompanying paperwork. The
electronic storage in their database gives immediate access to subsequent departments or providers regarding the
patient's care to date, notation of previous or present medications, notification of allergies, and establishes a history
on the patient to facilitate healthcare delivery regardless of geographical distance or location.

The term transcript or "report" as it is more commonly called, is used as the name of the document (electronic or
physical hard copy) which results from the medical transcription process, normally in reference to the healthcare
professional's specific encounter with a patient on a specific date of service. This report is referred to by many as a
"medical record". Each specific transcribed record or report, with its own specific date of service, is then merged
and becomes part of the larger patient record commonly known as the patient's medical history. This record is often
called the patient's chart in a hospital setting.

Medical transcription encompasses the MT, performing document typing and formatting functions according to an
established criteria or format, transcribing the spoken word of the patient's care information into a written, easily
readable form. MT requires correct spelling of all terms and words, (occasionally) correcting medical terminology or
dictation errors. MTs also edit the transcribed documents, print or return the completed documents in a timely
fashion. All transcription reports must comply with medico-legal concerns, policies and procedures, and laws under
patient confidentiality.
In transcribing directly for a doctor or a group of physicians, there are specific formats and report types used,
dependent on that doctor's speciality of practice, although history and physical exams or consults are mainly utilized.
In most of the off-hospital sites, independent medical practices perform consultations as a second opinion, pre-
surgical exams, and as IMEs (Independent Medical Examinations) for liability insurance or disability claims. Some
private practice family doctors choose not to utilize a medical transcriptionist, preferring to keep their patient's
records in a handwritten format, although this is not true of all family practitioners.

Currently, a growing number of medical providers send their dictation by digital voice files, utilizing a method of
transcription called speech or voice recognition. Speech recognition is still a nascent technology that loses much in
translation.[7] For dictators to utilize the software, they must first train the program to recognize their spoken words.
Dictation is read into the database and the program continuously "learns" the spoken words and phrases. [8]

Poor speech habits and other problems such as heavy foreign accents and mumbling complicate the process for both
the MT and the recognition software. An MT can "flag" such a report as unintelligible, but the recognition software
will transcribe the unintelligible word(s) from the existing database of "learned" language. The result is often a
"word salad" or missing text. Thresholds can be set to reject a bad report and return it for standard dictation, but
these settings are arbitrary. Below a set percentage rate, the word salad passes for actual dictation. The MT
simultaneously listens, reads and "edits" the correct version. Every word must be confirmed in this process. The
downside of the technology is when the time spent in this process cancels out the benefits. The quality of
recognition can range from excellent to poor, with whole words and sentences missing from the report. Not
infrequently, negative contractions and the word "not" is dropped all together. These flaws trigger concerns that the
present technology could have adverse effects on patient care. Control over quality can also be reduced when
providers choose a server-based program from a vendor Application Service Provider (ASP).

Downward adjustments in MT pay rates for voice recognition are controversial. Understandably, a client will seek
optimum savings to offset any net costs. Yet vendors that overstate the gains in productivity do harm to MTs paid by
the line. Despite the new editing skills required of MTs, significant reductions in compensation for voice recognition
have been reported. Reputable industry sources put the field average for increased productivity in the range of 30%-
50%; yet this is still dependent on several other factors involved in the methodology. Metrics supplied by vendors
that can be "used" in compensation decisions should be scientifically supported.

Operationally, speech recognition technology (SRT) is an interdependent, collaborative effort. It is a mistake to treat
it as compatible with the same organizational paradigm as standard dictation, a largely "stand-alone" system. The
new software supplants an MT's former ability to realize immediate time-savings from programming tools such as
macros and other word/format expanders. Requests for client/vendor format corrections delay those savings. If
remote MTs cancel each other out with disparate style choices, they and the recognition engine may be trapped in a
seesaw battle over control. Voice recognition managers should take care to ensure that the impositions on MT
autonomy are not so onerous as to outweigh its benefits.

Medical transcription is still the primary mechanism for a physician to clearly communicate with other healthcare
providers who access the patient record, to advise them on the state of the patient's health and past/current treatment,
and to assure continuity of care. More recently, following Federal and State Disability Act changes, a written report
(IME) became a requirement for documentation of a medical bill or an application for Workers' Compensation (or
continuation thereof) insurance benefits based on requirements of Federal and State agencies.

Curricular requirements, skills and abilities[edit]

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[edit]

Sound Knowledge of basic to advanced medical terminology is a must.

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[edit]
 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