WHAT IS MEDICAL TRANSCRIPTION?

Medical Transcription is the act of translating from oral to written form the record of a persons medical history, diagnosis, prognosis, and outcome. Medical Transcriptionist is a medical language specialist who transcribes dictation by physicians and other healthcare providers in order to document patient care. ROLE OF MEDICAL TRANSCRIPTIONISTS Interprets, translates, and edit medical dictation for content and clarity to produce a permanent medical record.

now Association for Healthcare Documentation Integrity (AHDI), which has developed a competency profile (COMPRO) and a model curriculum for transcription educators, as well as a model job description. Through the efforts of AAMT, medical transcriptionists have become recognized as healthcare professionals with expertise in medical language. Physicians and other healthcare providers employ state-of-the-art electronic technology to dictate and transmit highly technical and confidential information for their patients. These medical professionals rely on skilled medical transcriptionists to transform spoken words into comprehensive records that accurately communicate medical information.

The Modern Healthcare Team MT: Partners in Medical Communication Understanding the Profession of Medical Transcription Transcription has existed since the beginning of medical care and research. Ancient cave writings attest to the earliest forms of healthcare documentation. While the medium changed from metal plates to clay tablets, to hieroglyphs on temple walls, to papyrus, to parchment, to paper, and most recently to electronic files, the reasons for maintaining records have always been the sameto record an individual's health care and the achievements in medical science. Until the 20th century, physicians served as both providers of medical care and scribes for the medical community. After 1900, when standardization of medical data became critical to research, medical stenographers replaced physicians as scribes, taking their dictation in shorthand.

Frequently Asked Questions about Medical Transcription WHAT DOES A MEDICAL TRANSCRIPTIONIST NEED TO KNOW? Medical understanding is critical for the professional medical transcriptionist. Medical transcription requires a practical knowledge of medical language, anatomy, physiology, disease processes, pharmacology, laboratory medicine, and the internal organization of medical reports. A medical transcriptionist is truly a medical language specialist who must be aware of standards and requirements that apply to the health record, as well as the legal significance of medical transcripts. Reports of patient care take many forms, including histories and physical examinations, progress reports, emergency room notes, consultations, operative reports, discharge summaries, clinic notes, referral letters, radiology reports, pathology reports, and an array of documentation spanning more than

MEDICAL TRANSCRIPTION Medical Transcriptionists as Professionals Since 1978, medical transcriptionists have been represented by a professional organization, the American Association for Medical Transcription (AAMT),

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60 medical specialties and subspecialties! WHAT DO MEDICAL TRANSCRIPTIONISTS STUDY? To prepare for this profession, medical transcriptionists study medical language, including Greek and Latin suffixes, prefixes, and roots biological science, including anatomy and physiology of all body systems and various disease processes medical science medical and surgical procedures, involving thousands of instruments, supplies, appliances, and prosthetic devices pharmacology laboratory values, correlating laboratory test results with a patient's diagnosis and treatment use of medical reference materials and research techniques WHAT DOES QUALITY MEDICAL TRANSCRIPTION REQUIRE? above-average knowledge of English punctuation and grammar excellent auditory skills, allowing the transcriptionist to interpret sounds almost simultaneously with keyboarding advanced proofreading and editing skills, ensuring accuracy of transcribed material versatility in use of transcription equipment and computers, since transcriptionists may work in a variety of settings highly developed analytical skills, employing deductive reasoning to convert sounds into meaningful form CERTIFICATION The "Certified Medical Transcriptionist" (CMT) credential is offered via a two-part exam administered by the Medical Transcription Certification Commission at AAMT. Becoming a CMT may lead to increased pay but requires a commitment to and an investment in one's own professionalism.

Philippines: NC II Certificate for Medical Transcription by TESDA WHY HAVEN'T I HEARD ABOUT MEDICAL TRANSCRIPTION BEFORE? While medical transcription is among the most fascinating of allied health professions, the general public knows little about those who practice this skill. It was not until 1999 that the US Department of Labor assigned a separate job classification (Standard Occupational Classification #31-9094) so that statistics could be gathered on medical transcriptionists. Before that, transcriptionists were misclassified as typists, word processors, medical secretaries, and dictating machine operators. Through the efforts of the American Association for Medical Transcription (AAMT), visibility and recognition of the profession have increased, and the terms medical transcriptionist and medical language specialist have gained widespread acceptance. Medical transcriptionists work in settings that are usually far removed from the examining rooms, clinics, and hospital floors where health care is provided. Patients rarely have the opportunity to hear about those who transcribe their medical reports, and medical transcriptionists rarely meet the subjects of their work. Through the efforts of the American Association for Medical Transcription (AAMT), visibility and recognition of the profession have increased, and the terms medical transcriptionist and medical language specialist have gained widespread acceptance. EMPLOYMENT FOR MEDICAL TRANSCRIPTIONISTS Medical transcriptionists use their talents in a variety of healthcare settings, including doctors' offices, public and private hospitals, teaching

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hospitals, medical transcription businesses, clinics, laboratories, radiology and pathology departments, insurance companies, medical libraries, government medical facilities, rehabilitation centers, legal offices, research centers, veterinary medical facilities, and associations representing the healthcare industry. Medical transcriptionists work with physicians and surgeons in multiple specialties. They work with pharmacists, therapists, technicians, nurses, dieticians, social workers, psychologists, and other medical personnel. Some transcriptionists choose to work at home as employees of transcription businesses or hospitals. Qualified medical transcriptionists who wish to expand their professional responsibilities may become quality assurance specialists, supervisors, managers, department heads, or owners of medical transcription businesses. Experienced medical transcriptionists may become teachers, working in schools and colleges to educate future medical transcriptionists. MEDICAL TRANSCRIPTION AS GOOD HOME-BASED BUSINESS Medical transcription is a medical language specialty. Fluency in this language is not accomplished merely by completing a basic terminology course and installing a spellchecker on a computer! The transcriptionist working from home must make a significant investment in equipment and reference materials and be willing to make frequent updates to both in order to keep up with rapidly changing technology and terminology. Careful planning and the advice of legal and financial experts are essential to the success of a home-based business. AHDI advises that the individual considering a home-based medical transcription business first gain experience in a healthcare facility or transcription business under the

direction of experienced and qualified medical transcriptionists.

WHAT MAKES MEDICAL TRANSCRIPTION AN ATTRACTIVE CAREER CHOICE? Medical transcription provides unlimited intellectual challenge and the opportunity to make a unique contribution to quality health care and service. Health care is a rapidly growing industry, and the demand for quality documentation is increasing. The profession provides a high level of job security, and skilled medical transcriptionists may receive a premium for their services. Because their services are in demand, transcriptionists are often able to arrange convenient and flexible work schedules. Medical transcription is a portable skill that allows for professional and geographic mobility. Age restrictions are seldom found, with great value being placed on the experience and knowledge of the wellseasoned transcriptionist. Medical transcription can be a lifelong, satisfying career, providing the constant challenge of an expanding and advancing technology. The changes occurring in the healthcare industry promise to provide even more challenges to the forward-looking medical transcriptionist.

THE CHARACTERISTICS OF A MEDICAL TRANSCRIPTIONIST Medical transcription professionals are word specialists self-starters perfectionists independent by nature self-disciplined TECHNOLOGIES USED IN MEDICAL TRANSCRIPTION

Technology: INTRODUCTION TO DIFFERENT TOOLS AND

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EQUIPMENTS FOR MEDICAL TRANSCRIPTION Who were the first medical transcriptionists? Although no one really knows for sure, it is quite possible that medical transcription has it origins as far back as ancient Egypt. It is not difficult to imagine a physician dictating medical findings to a scribe who carefully recorded them. Transcription as we know it began in the 1950s, when machine dictation came into its own, displacing written shorthand as a method of recording physician notes. Utilizing such recording media as wax cylinders, plastic belts, and vinyl disks, physicians dictated their reports, and transcription was done using manual typewriters. Necessary copies and in hospital work there were often three or more were made using separate sheets of carbon paper. Reel-to-reel and cassette tapes (now referred to as analog dictation) came into use a few years later, along with electric typewriters. Toward the end of the 1960s, office workers everywhere were delighted with the advent of a remarkable innovation the self-correcting electric typewriter. Transcription continued its evolutionary path in the 1970s with the appearance of the word processor, which allowed production and storage of reports in an electronic environment. Recording was still done chiefly on magnetic tape, and many hospitals had central recording systems that featured endless loops of magnetic tape residing in huge tanks, allowing dictation from workstations within the hospital environment and later from outside the hospital via telephone. The cassette tape gained in popularity throughout the 1970s and remained the dictation medium of choice in hospitals and physician offices for years. Physician offices in particular utilized the handheld microcassette dictation machine, which allowed doctors to dictate anywhere, at any time. Such devices are still in use today.

Management of cassette tapes by the dozens, however, presented a daunting task for transcription managers everywhere. Electronic word processors gave way to personal computers with wordprocessing software in the 1980s, and a revolution in information processing began taking place, particularly in the field of medicine. While magnetic tape was still the most common method of recording dictation, transcribing machines were improving. Multi-tape dictation systems began making remote dictation and transcription common in every environment, even the small home office. The introduction of telestaffing units made it possible for transcriptionists to work in a variety of locations far away from sites of dictation. The development of sophisticated copying machines assured that transcriptionists would no longer have to deal with their old nemesis carbon paper. The 1990s brought us digital dictation dictation recorded directly into computers and managed by computers. Digital voice files can be stored, transferred, and manipulated totally by computer. The sound quality of digital recording is far better than that produced on analog tapes, making transcription easier and providing many more opportunities for remote transcription. Digital dictation can be transferred over telephone lines via computer modems, transcribed live or re-recorded for later transcription, and even transferred by WAV (waveform audio format) file. Using FTP (file transfer protocol), encrypted WAV files can be transferred between computers that are connected via the Internet, eliminating long-distance costs involved with telephone transfers. In essence, a transcriptionist can live anywhere, even in extremely remote areas, and still work for a transcription service or medical facility using digital dictation technology. Editors and proof-

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readers can work from other remote locations, accessing transcribed reports and providing assistance and corrections on digitally produced documents, then transferring finished transcripts to a client. Of course, remote transcription requires transcriptionists who are not only highly skilled and experienced, but also very knowledgeable about computers and digital technology. Digital technology has turned medical transcription into a global industry, allowing transfer of voice files to offshore locations such as India, Ireland, Jamaica, the Philippines, and the Bahamas. Many American transcription services doing business offshore or overseas have established transcriptionists training programs in the foreign locations, where labor costs are much lower and new transcriptionist jobs have the potential for improving the local standard of living. Voice files are transferred to the foreign location via telephone lines or the Internet. Transcription is done by the trainees, and proofreading and editing are performed either by American MTs in the foreign country or by U.S.-based personnel. The completed transcription is then returned to the client, all within tight turnaround times. The client may not even be aware that the dictation left the city in which it originated. As technology becomes more affordable, more dictated material may be forwarded to offshore locations for transcription. The greatest obstacle to successful offshore transcription will continue to be the foreign transcriptionists difficulty in understanding idiomatic American English.

5. Foot pedal COMPUTERS AND NETWORKS FILE SERVERS AND WORKSTATIONS Features: 1. System unit 2. Mouse 3. Printer 4. Keyboard 5. Monitor 1. 2. 3. 4. 5. 6. 7. 8. SOFTWARES Operating Systems (for File server and work stations) MSWord Word Expander Quick Look Reference Stedmans Medical Dictionary Spellers The Language of Medicine Express Scribe

Operating Systems An operating system (sometimes abbreviated as "OS") is the program that, after being initially loaded into the computer by a boot program, manages all the other programs in a computer. The other programs are called applications or application programs. The application programs make use of the operating system by making requests for services through a defined application program interface (API). In addition, users can interact directly with the operating system through a user interface such as a command language or a graphical user interface (GUI). Ex. DOS, Windows, PCDOS, MACOS, Linux, UNIX MSWord Microsoft Word is a word processing program designed to help you create and edit letters, reports, mailing lists, and tables as easily as possible. Word Expander Software Allows transcription in shorthand form and can be customized by a

TOOLS USED IN MT 1. Computers 2. Digital Dictation 3. Word Expander Software 4. Earphones

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transcriptionist as to his/her specifications Provide a number of brief forms for common words and terms (i.e. t=the, tp=the patient..)

1.

Dictionary Definitions of words Correct spelling Pronunciations Stedman Medical Dictionary Merriam-Webster Dictionary One Look Random House Unabridged Dictionary Word Spellers Quick word searching List of words Correct spelling Word division Pronunciation

Quick Look Drug Reference Provides correct spelling of drugs(generic or brand names) Provides also the details of drugs (i.e. use, chemical composition, dosage, etc.,) Stedmans Medical Dictionary Provides wealth of words with definitions, pronunciations, and etymology of main entries. Is essential for the accurate transcription of dictated medical reports. Express Scribe Software Express Scribe is a professional audio player software designed to assist the transcription of audio recordings. It is installed on the typist's computer and controlled using the keyboard (with 'hot' keys) and/or foot pedal controls. This computer transcriber application features variable speed wave playback, foot pedal operation, file management and more.

2.

3.

Textbooks Provide detailed and comprehensive explanations Less commonly used; not handy May take MTs time when used in researching Large references

4. Specialty References (Stedmans

Electronic References) Cardiopulmonary, Orthopedic, Radiology, Pathology, Obstetrics and Gynecology, Gastroenterology, Ophthalmology, Neurology, Medical Tools and Equipments, Orthopedic BROWSE ON INDEX Use Browse on Index to look through the complete A-to-Z word list. Browsing starts when you type a letter or series of letters. Browse on Index is the most versatile, especially if you are unsure of the spelling of a term. BROWSE ON APPENDICES Each appendix is listed alphabetically by name. Provide valuable information on a variety of subjects Anatomy Tables; Blood Groups; Common Medical Abbreviations; Common Prefixes, Suffixes, and Combining Forms

WORD RESEARCH TECHNIQUES Learning Outcomes: 1. Identify the types of references that can be used in medical transcription. 2. Enumerate the techniques of word research in medical transcription. 3. Apply these tools and research techniques to the practice of medical transcription. IMPORTANCE OF REFERENCES IN MEDICAL TRANSCRIPTION Provide information spelling, definitions, pronunciations, examples, images TYPES OF REFERENCES

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Diagnosis-Related Groups; Laboratory Reference Range Values; Symbols; Temperature Equivalents; and Weights & Measures.

TRANSCRIBE REPORTS MORE THAN ONCE Some words cannot be identified the second, third, or fourth time around FRUSTRATED??? Have you exhausted all efforts in researching??? Ask the opinion of other MTs Access to past medical reports Previous reports of the patient Ask the physician May leave a blank

SEARCH ON HEADWORD You can use Wildcard Characters (*) with Search on Headword to narrow or expand your search results. VERIFY UNFAMILIAR WORDS with the REFERENCES -To ENSURE that what is being transcribed makes SENSE UNCLEAR WORDS Leave blank Clues revealed as dictation goes along Relisten to the word UNABLE TO LOCATE THE WORD? Think of other letters other than the sound heard k may be ch (chalazion) z or an s may be x (xiphisternum)

PEOPLE SEARCH Common sites: Intelius.com Veromi.com PHYSICIAN/DOCTOR SEARCH Common sites: WebMD DrScore AMA (American Medical Association) .

ALWAYS SEARCH at the MAIN ENTRIES or the COMMON TERM

Mayo scissor, search first under scissor

MAIN ENTRY NOT ALWAYS THE SECOND WORD retinitis pigmentosa = retinitis auditory agnosia = auditory

WORD NOT UNDER THE MAIN ENTRY? Think of an alternative entry. test for sign; cardiac for heart toes or fingers for digits

DIFFICULT REPORTS Regular breaks to facilitate progression with a clear mind

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