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Medical Transcriptionists - What They Do

Medical transcriptionists listen to dictated recordings made by physicians and other healthcare professionals and transcribe them into medical reports, correspondence, and other administrative material. They generally listen to recordings on a headset, using a foot pedal to pause the recording when necessary, and key the text into a personal computer or word processor, editing as necessary for grammar and clarity. The documents they produce include discharge summaries, medical history and physical examination reports, operative reports, consultation reports, autopsy reports, diagnostic-imaging studies, progress notes, and referral letters. Medical transcriptionists return transcribed documents to the physicians or other healthcare professionals who dictated them for review and signature or correction. These documents eventually become part of patients' permanent files.

To understand and accurately transcribe dictated reports, medical transcriptionists must understand medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. They also must be able to translate medical jargon and abbreviations into their expanded forms. To help identify terms appropriately, transcriptionists refer to standard medical reference materials—both printed and electronic; some of these are available over the Internet. Medical transcriptionists must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for keeping patient information confidential.

Experienced transcriptionists spot mistakes or inconsistencies in a medical report and check to correct the information. Their ability to understand and correctly transcribe patient assessments and treatments reduces the chance of patients receiving ineffective or even harmful treatments and ensures high-quality patient care.

Currently, most healthcare providers use either digital or analog dictating equipment to transmit dictation to medical transcriptionists. The Internet has grown to be a popular mode for transmitting documentation. Many transcriptionists receive dictation over the Internet and are able to quickly return transcribed documents to clients for approval. Also, because of the popularity of using the Internet to transmit documentation, many medical transcription departments are beginning to work closely with programmers and information systems staff to stream in voice communication that provides seamless data transfers through network interfaces. This practice allows medical transcriptionists the convenience of having hand-held personal computers or personal data assistants (PDAs) that utilize software for dictation.

Another increasingly popular method uses speech recognition technology, which electronically translates sound into text and creates drafts of reports. Transcriptionists then format the reports; edit them for mistakes in translation, punctuation, or grammar; and check for consistency and any wording that doesn't make sense medically. Transcriptionists working in specialties such as radiology or pathology, which have standardized terminology, are more likely to use speech recognition technology, a medium that will become more widespread in all specialties as it becomes more sophisticated and is better able to recognize and more accurately transcribe diverse modes of speech.

Medical transcriptionists who work in physicians' offices may have other office duties, such as receiving patients, scheduling appointments, answering the telephone, and handling incoming and outgoing mail.

Work Environment
The majority of these workers are employed in comfortable settings, such as hospitals, physicians' offices, transcription service offices, clinics, laboratories, medical libraries, government medical facilities, or their own homes. Many medical transcriptionists telecommute from home-based offices.

Workers usually sit in the same position for long periods. They can suffer wrist, back, neck, or eye problems caused by strain and risk repetitive motion injuries such as carpal tunnel syndrome. The constant pressure to be accurate and productive also can be stressful.

Many medical transcriptionists work a standard 40-hour week. Self-employed medical transcriptionists are more likely to work irregular hours—including part time, evenings, and weekends. Some may be on call at any time.

Education & Training Required
Employers prefer to hire transcriptionists who have completed postsecondary training in medical transcription offered by many vocational schools, community colleges, and distance-learning programs.

Completion of a 2-year associate’s degree or 1-year certificate program—including coursework in anatomy, medical terminology, legal issues relating to healthcare documentation, and English grammar and punctuation—is highly recommended, but not always required. Many of these programs include supervised on-the-job experience. Some transcriptionists, especially those already familiar with medical terminology from previous experience as a nurse or medical secretary, become proficient through refresher courses and training.

Formal accreditation is not required for medical transcription programs. However, the Approval Committee for Certificate Programs (ACCP)—established by the Association for Healthcare Documentation Integrity (AHDI) and the American Health Information Management Association—offers voluntary accreditation for medical transcription programs. Although voluntary, the completion of an ACCP-approved program may be required for transcriptionists seeking certification.

Certifications Needed (Licensure)

Other Skills Required (Other qualifications)
The AHDI awards two voluntary designations; Registered Medical Transcriptionist (RMT) and Certified Medical Transcriptionist (CMT). Medical transcriptionists who are recent graduates of medical transcription educational programs or who have fewer than 2 years’ experience in acute care may become a registered RMT. The credential is awarded upon successfully passing the AHDI level-1 registered medical transcription exam. The CMT designation requires at least 2 years of acute care experience using different format, report, and dictation types in multiple-specialty surgery areas. Candidates also must earn a passing score on a certification examination. Because medicine is constantly evolving, medical transcriptionists are encouraged to update their skills regularly. In order to be recertified, RMTs and CMTs must pay a recertification fee. In addition to the fee, RMTs must earn a minimum of 30 continuing education credits in required categories during their 3-year cycle. CMTs must successfully complete an online course and final exam during the 3-year cycle. As in many other fields, certification is recognized as a sign of competence.

Graduates of an ACCP-approved program who earn the RMT credential are eligible to participate in the Registered Apprenticeship Program sponsored by the Medical Transcription Industry Association through the U.S. Department of Labor. The program offers structured on-the-job learning and related technical instruction for qualified medical transcriptionists entering the profession.

In addition to understanding medical terminology, transcriptionists must have good English grammar and punctuation skills and proficiency with personal computers and word-processing software. Normal hearing acuity and good listening skills also are necessary. Employers usually require applicants to take preemployment tests.

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