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Medical transcriptionists transcribe (type into printed format) a dictated (oral) report recorded by a doctor or another health care professional. They work for primary care physicians as well as health care professionals in various medical specialties, including cardiology, immunology, oncology, podiatry, radiology, and urology.
Many medical transcriptionists now use speech recognition software to electronically create documents from oral dictation, eliminating much of their typing work. They then review the computer-generated document while listening to the original recording, making corrections to the draft as necessary. After creating a report, medical transcriptionists review it and make corrections to grammar, punctuation, and spelling. They read it to be sure it is clear, consistent, and complete and does not contain any errors. Medical transcriptionists are expected to edit for clarity and make grammar corrections; therefore, the final report does not need to be identical to the original dictation in those respects.
The report consists of information gathered during a patient's office appointment or hospital visit and covers the patient's medical history and treatment. Doctors dictate information about patient consultations, physical examinations, results from laboratory work or X rays, medical tests, psychiatric evaluations, patient diagnosis and prognosis, surgical procedures, a patient's hospital stay and discharge, autopsies, and so on. Often doctors will use abbreviations while dictating. The medical transcriptionist must type out the full names of those abbreviations.
The report becomes a permanent part of a patient's medical record and is referred to by the same doctor or other members of the patient's health care team during future office visits or when determining future medical treatment, so it must be accurate. This includes dates and the spelling of medications, procedures, diseases, medical instruments and supplies, and laboratory values.
Being a medical transcriptionist is not all about typing and proofreading. Medical transcriptionists are familiar with medical terminology. When recording their reports, doctors use medical terms that are relevant to a patient's condition and treatment. Such terms might be names of diseases or medications. Medical transcriptionists understand what these medical terms mean and how they are spelled. They understand enough about various diseases and their symptoms, treatments, and prognoses as to be able to figure out what a doctor is saying if the recording is a little garbled. They have a good understanding of medicine and know about human anatomy and physiology. If what the doctor says on the recording is unclear, a medical transcriptionist often has to determine the appropriate word or words based on the context. However, medical transcriptionists never guess when it comes to medications, conditions, medical history, and treatments. A patient could receive improper and even damaging treatment if a diagnosis is made based on a report containing errors. Medical transcriptionists contact the doctor if they are uncertain or they leave a blank in the report, depending on the employer's or client's expectations and guidelines. After the medical transcriptionist reviews the report, it is given to the doctor, who also reviews it and then signs it if it is acceptable—or returns it to the transcriptionist for correction, if necessary. Once it has been signed, the report is placed in the patient's permanent medical file.
While some transcriptionists only do transcribing, other transcriptionists, often those who work in doctors' offices or clinics, may have additional responsibilities. They may deal with patients, answer the phone, handle the mail, and perform other clerical tasks. And transcriptionists may be asked to file or deliver the reports to other doctors, lawyers, or other people who request them.
A growing number of medical transcriptionists work out of their homes, either telecommuting as employees or subcontractors or as self-employed workers. As technology becomes more sophisticated, this trend is likely to continue. Medical transcriptionists who work out of their homes have some degree of mobility and can live where they choose, taking their jobs with them. These workers must keep up to date with their medical resources and equipment. Because terminology continues to change, medical transcriptionists regularly buy revised editions of some of the standard medical resources.