Medical Transcription: Process, Guidelines, Notes

From this definition comes the meaning for transcription “to change the spoken word to the written word”.

Medical transcription is an exciting vitally important carrier. Fascination and appreciation for medicine are developed by the working transcriptionist. Transcriptionists are known for their love for words.

Part of the joy of being a transcriptionist knows that you are the modern communicator in the medical field. When you have completed your course of study, you will be prepared to seek employment in a variety of medical settings or become a self-employed transcriptionist. Other hospital departments that require the skills of medical transcriptionists are radiology, pathology, outpatient surgery, admissions business, and executive.

Public health clinics, school health facilities, private insurance agencies, specialized typing, and transcription agencies, large legal firms, military medical departments, and governmental agencies also offer challenging opportunities for professional transcriptions. 

Medical research is conducted in many settings and this particular field may offer you again the opportunity to participate in what is going on as well as to record it.  You might decide to work for a private transcribing service.

The word transcription is derived from trans and scriba. Trans means across, beyond through, to change: scriba means an official writer. From this definition comes the meaning for transcription “to change the spoken word to the written word”.

Medical Transcription Process

Let’s Start to Learn Medical Transcription full Course with important Chapters given below

First of all, the basic question comes to mind What is Medical Transcription (MT)?

Answer is

Medical transcriptionists type (or transcribe) dictated audio reports of doctor-patient interactions.

Can you transcribe/type a doctor’s dictation accurately? Do you like to learn medical terminology? Would you like to work from home? Maybe it’s time to consider a career in Medical Transcription.

When you receive reports from doctors, Given below headings is very important to understand the process –

(Audio + Visual) Reports

Medical transcriptionists type (or transcribe) dictated audio reports of doctor-patient interactions.

Initial Evaluation Report

Also Called Doctor’s First Visit of Occupational Injury and Illness Report

Progress Report

Also called Re-evaluation Report or Follow up Report

Therapy Note

It includes Physiotherapy, Chiropractic, Acupuncture, and Occupational Therapy

Med-legal Reports

It includes AME, QME, PQME, and Permanent and Stationary Reports

Emergency Department Report

History and Physical Report

Operative Report

This report should be dictated or written in the medical report immediately after surgery.

Discharge Summary Note

Discharge Summary Note required for each patient who is discharged from a hospital

Radiology Reports

It deals with the use of X-rays for diagnosis and therapeutic purposes.

Laboratory Reports

Certification for Medical Transcriptionist

After at least three years of experience in performing medical transcription in a variety of medical and surgical specialties, a qualified medical transcriptionist may wish to take the certification examination offered by the American association for medical transcription (AAMT). Those passing the examination become Certified Medical Transcriptionists (CMTs).

A CMT is recognized as a professional medical transcriptionist who participates in an ongoing program of continuing medical education to increase knowledge of medicine and improve skills in the medical transcription field. AAMT also offers a specialty examination in radiology.

Do not learn heavy, learn easy guidelines to become a good medical transcriptionist.

Medical Transcription Guidelines

1 – SLASH, DIAGONAL

 The slash(/), is also known as the diagonal, virgule, or solidus, is used for a variety of purposes.

1 – Use a slash to refer equally to the entity on each side of the virgule or to both together, for example, when gender is not specified and does not matter.

E.g.         his/her

2 – Slash may be used to separate numerals representing the month, day, year in table and figures, This form is also used for admission and discharge dates when  giving patient demographic data, Do not use hyphens instead of virgules. Do not use virgules in textual matter, i.e. within reports

E.g.         Discharge: 5/1/2020

3 – Use a Slash to imply duality, i.e., that the entity on each side of the virgule is the same as the other. When the two entities are not the same E.g.         physician/patient

FORMAT:

1.  No heading should be added when not dictated.  If a physician is dictating the physical examination in a report and begins to dictate the laboratory results or x-ray results without giving a heading for a new section, the transcriptionist should start a new paragraph before transcribing the laboratory or x-ray results but with no heading.

Note: “New line” means new paragraph.

Example

Dictated	PHYSICAL EXAMINATION: The fracture site was tender to palpation. He had good sensation and circulation in the leg. Multiple views of the tibia revealed there as a stair-step‑type fracture at the distal portion of the tibia. The CBC and differential were normal.
Transcribed	PHYSICAL EXAMINATION: The fracture site was tender to palpation. He had good sensation and circulation in the leg. Multiple views of the tibia revealed there was a stair-step-type fracture at the distal portion of the tibia. The CBC and differential were normal.

2. There should be no abbreviations in the headings even if the doctor is dictating it.

Example

Dictated: HPI Transcribed: History of Present Illness

3. In headings, when diagnosis (singular form) is dictated, it should be transcribed as diagnosis even if more than one is listed. Should not change it to diagnoses (plural form).

4. The diagnoses (admitting diagnosis, discharge diagnosis, etc.) should be listed vertically, whether or not numbers are dictated. The diagnoses should be numbered if dictated and not numbered if not dictated, but should always be listed vertically. If a physician begins to number the diagnosis and then gives only one diagnosis, then the number should be omitted (number 1 is not required without number 2) If a physician, while dictating a list of diagnoses, loses track of the next number or gives the wrong number or just says ‘number next’, the transcriptionist should be aware of it and number it correctly.

Proofreading and Making Corrections

The largest medical vocabulary, the fastest fingers, and the latest equipment all mean nothing if the final document does not reflect the professional quality for which you are striving.  Proper proofreading skills can give you this quality, and lack of it can cause embarrassment and poor self-image.  You need these skills right now because you will have to check your work carefully to earn high marks on the copy you submit for grading. 

Later on, you will want to have excellent skills when you begin your career as a transcriptionist.  Since accurate written communication is so important today, the ability to proofread your work and to work without supervision will give you an advantage; you may well be promoted on these bases to supervisory capacity.

A great deal of self-discipline is required of the transcriptionist who wishes to turn out a perfect copy. No matter how accurate a speller you are and no matter how highly trained your punctuation, capitalization, and mechanical skills, errors can and do occur, and it is necessary to approach every document you type with the attitude that errors may be present. A systematic search for error is then begun. Over half the mistakes made are due not to ignorance or carelessness, but to the inability to “see” the mistake or recognize it when we become too familiar with the material.

WHERE ERRORS OCCUR:

There are differences of opinion among teachers, students, and prospective employers as to what an error is and how important different errors are.  For example, transposed letters in the name of the drug could be very serious, whereas a capital letter typed offline, although upsetting to a fastidious instructor, would hardly be grounds for dismay on the part of the employer.

In fact, how far offline does a “galloping” capital letter have to be before it is an error? When does the improper spacing -between letters become an error, and what is the difference between a sloppy correction and a good one? There are many kinds of errors that are value judgments on the part of the student, teacher, or employer checking the paper.  Finally, the quality of paper used will also contribute to the ease with which errors are repaired.

There are, in fact, some kinds of errors that are “permissible” and the copy is still mailable; other errors are easily corrected; and, finally, some errors can be eliminated only by redoing the material.

On the other hand, you do not want to type so slowly to avoid making errors that your production drops or you become nervous about the errors you “might” be making instead, try to keep your errors to a minimum, learn to find those you do make, and learn to correct them quickly and easily.

When transcribing from equipment, you can look at your work while typing; therefore, you can see any mistakes you make and correct them as they occur.  You will gain skill with this in time, and it is easier and less time-consuming than redoing your work. Later, in rereading, you may discover an error that requires retyping because it went unnoticed as you worked.  Listed ahead to avoid grammar problems in particular.

ACCURACY: Medical records must be as accurate as you can type them.  This requires accuracy on the part of both dictator and transcriptionist.   The problem with accuracy sometimes is the meaning of the word “accuracy.” Who determines what is accurate?

Antonyms, Medical Eponyms, and Homonyms

Antonyms

An antonym is a whale word, a prefix, or a suffix that means the opposite of another word. To give an example from non-medical English, sad is the antonym of happy. Sometimes these antonyms cause spelling trouble because of their similarities in sound.

Medical Eponyms

Medical eponyms are adjectives used to describe specific operations, surgical instruments, diseases, and parts of the anatomy. Each of these words is the surname (or an adjective formed from the surname) of an individual who is prominently connected with the development or discovery of the disease, instrument, or surgical procedure. Currently, the American Medical Association recommends that an eponym not be used when a comparable medical term can be substituted for it. It is the dictator’s responsibility to dictate the proper term since in this instance the transcriptionist merely types what was heard.

Many anatomic eponyms are now written in lower case, such as a Eustachian tube, fallopian tube, and so forth. Words derived from eponymic names (parkinsonism, Addisonian, Cushingoid facies, and so forth) should not be capitalized.

To find the medical term or definition that corresponds to an eponym, look up the second term, the clue word.

English Homonyms

Homonyms are words that are similar in pronunciation but different in meaning and spelling. Sometimes these are called “phonetic pairs.” A few English examples are hare and hair, weak and week, and two, two, and to. If one of these words were dictated, knowing its meaning would help you decide how to spell it.

Medical Homonyms

Medical homonyms may prove somewhat tougher if you are not thoroughly versed in terminology or if the difficult word pairs have never been pointed out to you. Perhaps even now you are using an incorrect spelling of a word. Mastery of some of the more challenging ones can save you time and possibly embarrassment.

You will be confronted by homonyms throughout your career as a medical transcriptionist. A HETERONYM is a word that has the same spelling as another but a different meaning and a different pronunciation. For example, let’s take the word tear. It can mean a drop of water from the eye, or it can mean pulling or rip something apart.

Medical Chart Notes

Chart notes (also called Progress notes) are the formal or informal notes taken by the physician when he or she meets with or examines a patient.

Those notes are a part of the patient’s permanent medical record. Although medical reports are used mainly to assist the physician with the care of the patient, they can be reviewed by attorneys, other physicians, insurance companies, or the court. They must be neat, accurate, and complete.

“Accurate” means that they are transcribed verbatim (exactly as dictated), and “complete” requires that they are dated and signed or initialed by the dictator. For a chart to be admissible as evidence in court, the party dictating or writing entries should be able to attest that they were true and correct at the time they were written. The best indication of that is the physician’s signature or initials at the end of each typed note. The hospital will insist that the physician sign all dictated material and all entries he or she makes on the patient’s record.

Furthermore, before copies of records leave the office, the originals must be checked for accuracy; and if they have not been signed before, they must be signed now. Any liability of the medical assistant, personally, is of small significance unless there are unusual circumstances such as negligence, willfulness, or malice. Physicians cannot easily shift the blame to an assistant, because the faulty records are his or her responsibility as long as the proper procedure for release of information has been established. If a medical secretary or transcriptionist is at fault in recording improperly, the physician has the right to discharge him or her for inefficiency, and this is a peril for the careless assistant.

The physician should try to dictate as soon as he or she is finished seeing a patient and the details are still fresh in his or her mind. Some physicians have also found it helpful to dictate the notes with the patient present. This allows the physician to ask for any details that may have been overlooked in the initial history taking; it also allows him to re-instruct the patient on medication.