Medical Transcription
Let's break the word transcription down. The main word is transcribe: - is related to the word transfer, which is "to convey or cause to pass from one place, person, or thing to another": scribe is both a pronoun and a verb. A scribe (pronoun) is one who records things in written form; to scribe (verb) is to write or inscribe. Being a scribe in, say, ancient Greece, was a highly esteemed, well educated and highly specialized person and position in society due to various factors, not the least of which being that they possessed (and still possess) a natural penchant for accuracy. In some form or other it has existed since the dawn of civilization with rudimentary records in the form of drawings scratched onto prehistoric cave walls, clay tablets, hieroglyphics, parchment and finally to paper.
The father of modern medicine, Hippocrates, had physician notes as a written record of medical actions and also served as a basic guide for reference for future patient care. Not much has changed, though obviously the use of the records has expanded exponentially to include the patient record and from that obtain all of the information used in the billing and reimbursement process.
The need for dead-on accuracy from transcribers of ancient times was due to the risk of creating distortions of meaning from one transcribed document to its successor document, parchment or tablet. Even one word wrong could lead to a completely inaccurate rendering two hundred years down the road. Accuracy in medical transcription is critical in the modern sense to ensure proper care delivery and clear communications among every facet of a record, its related diagnosis and procedure code, and billing, to say nothing of the risk management involvement on the legal side of things.
In the early 1900s, medical stenographers began taking dictation by shorthand; thereafter, dictation machines evolved. Virtually every visit to the doctor, every admission to the hospital, requires a comprehensive record of the encounter, including the diagnosis, treatment, and outcome. This is the material transcribed by the MT.
Physicians came to rely on the judgment and reasoning of experienced medical secretaries (as they were known in olden times prior to about 1966) to safeguard the accuracy and integrity of medical dictation, leading to medical transcription evolving into a medical language specialty. Medical transcription is one of the most sophisticated of the allied health professions, creating an important partnership between healthcare providers and those who document patient care.
While medical transcription is among the most fascinating of allied health professions, the general public knows little about this skill and who practices it, and even how it is done. 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.
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.
Medical Transcription Process
When a patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past problems. The doctor may do a physical examination, conduct various laboratory or diagnostic studies, make a diagnosis, and then decides on a plan of treatment and discusses it with the patient. After the patient leaves, the doctor uses a voice recording device to record the information about the interaction with the patient. This information is then sent to a medical transcriptionist and received as a voice file, who then listens to the voice file and transcribes it into the required format to make a medical record which is also a legal document that may be subpoenaed. The next time the patient visits the doctor, the doctor can call for the medical record. The doctor may also refill medications after seeing only the medical record.
It is important to have a properly written, edited and reviewed medical transcription document. If a medical transcriptionist accidentally typed a wrong medication or wrong diagnosis, the patient's life will be put at risk if the doctor will not review the document for its consistency. Both the doctor and the medical transcriptionist play an important role to make sure the transcribed dictation is correct and accurate. The doctor should speak slowly and concisely, especially when dictating medications or diseases, and the medical transcriptionist must possess hearing acuity, medical knowledge, and good reading comprehension.
Doctors often do not review their transcribed reports for accuracy. Add to this the fact that most doctors do not speak clearly or concisely, let alone slowly. Medical doctors are rarely accurate spellers. It is the job of the transcriptionist to look up the correct spelling of complex medical terms. Medicine in the U.S. is constantly changing. New equipment, new medical devices, new medications come on the market on a daily basis. Medical transcriptionists need to be creative and tenacious researchers in order to search for and find these new words.
Let's break the word transcription down. The main word is transcribe: - is related to the word transfer, which is "to convey or cause to pass from one place, person, or thing to another": scribe is both a pronoun and a verb. A scribe (pronoun) is one who records things in written form; to scribe (verb) is to write or inscribe. Being a scribe in, say, ancient Greece, was a highly esteemed, well educated and highly specialized person and position in society due to various factors, not the least of which being that they possessed (and still possess) a natural penchant for accuracy. In some form or other it has existed since the dawn of civilization with rudimentary records in the form of drawings scratched onto prehistoric cave walls, clay tablets, hieroglyphics, parchment and finally to paper.
The father of modern medicine, Hippocrates, had physician notes as a written record of medical actions and also served as a basic guide for reference for future patient care. Not much has changed, though obviously the use of the records has expanded exponentially to include the patient record and from that obtain all of the information used in the billing and reimbursement process.
The need for dead-on accuracy from transcribers of ancient times was due to the risk of creating distortions of meaning from one transcribed document to its successor document, parchment or tablet. Even one word wrong could lead to a completely inaccurate rendering two hundred years down the road. Accuracy in medical transcription is critical in the modern sense to ensure proper care delivery and clear communications among every facet of a record, its related diagnosis and procedure code, and billing, to say nothing of the risk management involvement on the legal side of things.
In the early 1900s, medical stenographers began taking dictation by shorthand; thereafter, dictation machines evolved. Virtually every visit to the doctor, every admission to the hospital, requires a comprehensive record of the encounter, including the diagnosis, treatment, and outcome. This is the material transcribed by the MT.
Physicians came to rely on the judgment and reasoning of experienced medical secretaries (as they were known in olden times prior to about 1966) to safeguard the accuracy and integrity of medical dictation, leading to medical transcription evolving into a medical language specialty. Medical transcription is one of the most sophisticated of the allied health professions, creating an important partnership between healthcare providers and those who document patient care.
While medical transcription is among the most fascinating of allied health professions, the general public knows little about this skill and who practices it, and even how it is done. 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.
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.
Medical Transcription Process
When a patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past problems. The doctor may do a physical examination, conduct various laboratory or diagnostic studies, make a diagnosis, and then decides on a plan of treatment and discusses it with the patient. After the patient leaves, the doctor uses a voice recording device to record the information about the interaction with the patient. This information is then sent to a medical transcriptionist and received as a voice file, who then listens to the voice file and transcribes it into the required format to make a medical record which is also a legal document that may be subpoenaed. The next time the patient visits the doctor, the doctor can call for the medical record. The doctor may also refill medications after seeing only the medical record.
It is important to have a properly written, edited and reviewed medical transcription document. If a medical transcriptionist accidentally typed a wrong medication or wrong diagnosis, the patient's life will be put at risk if the doctor will not review the document for its consistency. Both the doctor and the medical transcriptionist play an important role to make sure the transcribed dictation is correct and accurate. The doctor should speak slowly and concisely, especially when dictating medications or diseases, and the medical transcriptionist must possess hearing acuity, medical knowledge, and good reading comprehension.
Doctors often do not review their transcribed reports for accuracy. Add to this the fact that most doctors do not speak clearly or concisely, let alone slowly. Medical doctors are rarely accurate spellers. It is the job of the transcriptionist to look up the correct spelling of complex medical terms. Medicine in the U.S. is constantly changing. New equipment, new medical devices, new medications come on the market on a daily basis. Medical transcriptionists need to be creative and tenacious researchers in order to search for and find these new words.
Posts
0 comments
Post a Comment