A variety of medical reports are generated everyday in physician offices, clinics and hospitals. Physicians in private practice frequently dictate office chart notes, letters, initial office evaluations, history and physical examination.
Medical reports dictated in hospitals and medical centers are numerous. The documentation of medical records is necessary to satisfy regulatory and insurance provider requirements. Today doctors spend more time on patients than in documentation in order to make financial end meets.
The record should be in chronological, documented evidence of patients' initial database, initial evaluation, identified problems and needs, objectives of care, prescribed treatment and end results. The record may be paper, stored digitally in electronic format in computer or a combination of two. The record is the property of the hospital of office.
Transcription is a process where one can accurately and swiftly transcribe medical records dictated by doctors and others including history and physical reports, clinical and office notes, operative reports, consultation notes, discharge summaries, evaluation, lab report, x-ray and pathology reports. Voice recognition is one of the modern technologies.
Confidential information of the patient is converted to written document by the medical transcriptionist. He receives dictation by several methods which involves dictation by tape, digital system or voice files which are produced either through the use of digital recorder of digital phone system used by the dictator and through telephones.
He transcribes information with the help of earphones for hearing, a foot pedal for start or stop control and a word processing program.
Transcription requires good listening and language skills, speech recognition, computer skills, knowledge in grammar and punctuation, knowledge of medical terminology, anatomy, diagnostic procedures, pharmacology, treatment assessment, the legal and ethical issues surrounding medical reports, ability to edit for clarity, mistakes and inconsistencies.
The data is further scrutinized for grammar and clarity by a proof reader. After transcribing information in to a document, it is then forwarded to the dictator for review and signature. These documents then become the part of patient's permanent medical record.
The process of transcription starts when the patient visits the doctor. The doctor discusses the medical problems with the patient including the history of ailments. After consulting, the doctor may request to perform laboratory or diagnostic studies. After the diagnosis the doctor decides the treatment for the patient which is explained to the patient.
When the patient leaves, the doctor uses a voice recording device to record the information about the patient. This sound is digitized and sent to the offshore outsourcing service center as a WAVE file through satellite link. The digitized data is converted back to sound.
The transcriptionist listens to the dictation and transcribes. The transcribed files are sent out to quality control person who listen to the dictation and check the transcription. Corrections are made if required.
The transcribed report is transmitted back as word file. It is very important to have a properly formatted, edited and reviewed medical transcription.
The patient could be at risk, if the transcriptionist accidentally types wrong medication or wrong diagnosis and the doctor did not review the document for accuracy. Both the doctor and the transcriptionist play an important role to make sure the transcribed document is correct and accurate.
A transcriptionist is constantly challenged to learn with interesting, ever changing subject matter. There are always new medications and procedure, changing medical terminologies which make him learn constantly.
This profession which demands a very good coordination between the mind, ears, eyes and the hands. The job requires a lot of hardworking, dedication and commitment to deliver the best.