Introduction
Medical
transcription, widely known as MT, is one of the fastest growing fields in many
western and Asian countries, including India.
It is a process in which one accurately transcribes and edits the
content dictated by physicians and other health professionals concerning a
patient's health care. The majority of these
physicians and health professionals are from USA; however, there are dictators
from UK, Australia, and Canada also.
In
USA, when a patient visits a doctor, the doctor discusses his medical problems,
including his present history, past medical history, family history, social
history, habits, etc. Then, the doctor
performs physical examination on the patient.
He may also request some diagnostic and laboratory tests to be performed,
if necessary, so as to make proper diagnosis and treatment plan. After consulting the patient, the doctor uses
a voice recorder to record the necessary information given by the patient as
well as the findings obtained from physical examination. The voice file then goes to a medical
transcriptionist who listens to the whole dictation and transcribes the report
using proper format and guidelines given by the doctor. The transcriptionist uses headphone, foot
pedal, etc., to type out the report.
After completion, the transcriptionist sends the typed report to the
doctor, which is considered a legal document.
There
are mainly five types of report that are dictated by a dictator, e.g., History
and Physical Examination, SOAP Note, Consultation, Operative Report, and
Discharge Summary.
In
a nutshell, a medical report looks like the following:
PATIENT
NAME: xxxx xxxx
MR#: xxxxxxx
DOB:
00/00/0000
DATE
OF VISIT: 00/00/0000
HISTORY
OF PRESENT ILLNESS: The patient is an
82-year-old male who has a known history of hypertension and CAD. He reports that everything is
"okay." He describes
occasional headaches and little bit of cough with rare white sputum. He denies sore throat or chest pain. He reports occasional nausea but denies
abdominal pain, vomiting, or diarrhea.
He denies dysuria. He also
reports anxiety for which he takes Xanax p.r.n. He denies any rashes. He underwent previous PTCA and stenting
procedures last year. Since that time,
he has been relatively stable with medical management. He reports smoking occasionally. Typically, he smokes when he has a beer.
PAST
MEDICAL HISTORY:
1. Hypertension and CAD.
2. Chronic cough.
3. Dyslipidemia.
ALLERGIES: None.
MEDICATIONS: Aspirin 81 mg daily, Plavix 75 mg daily,
metoprolol 50 mg b.i.d. and Lipitor 10 mg q.h.s.
SOCIAL
HISTORY: He occasionally smokes. He does not abuse alcohol.
FAMILY
MEDICAL HISTORY: His mother died of colon
cancer. His father died of gastric
carcinoma. One brother has
hypertension.
PHYSICAL
EXAMINATION: Vital signs: Blood pressure 120/80, pulse 80, respirations
17, and temperature 98.2 degrees Fahrenheit.
He weighs 185 pounds. He is 5
feet 9 inches. In general, this is an
elderly-appearing, pleasant male, currently in no cute distress. Throat is benign. Neck is supple. Carotids have 2+ upstrokes bilaterally
without bruits. Chest has a normal AP
diameter. Lungs are clear to
auscultation and percussion. No
murmurs, clicks or gallops. Abdomen is
soft, nontender, and nondistended.
Good bowel sounds present. Face
is symmetrical. He has a normal gait.
DIAGNOSES:
1. Coronary artery disease.
2. Hypertension.
3. Chronic cough.
4. Dyslipidemia.
PLAN: The patient is advised to continue his medications
as prescribed. We will repeat labs
today. She will be followed up in
approximately four weeks’ time. At
that time, any changes in treatment plan or further treatment will be
determined.
|
Voice
Recognition Technology
In
this day and age, with the help of advanced technology, many providers use a
method of transcription called “speech or voice recognition.” Though the voice recognition software types
out the report without human intervention, it still cannot produce a 100%
accurate report and an experienced transcriptionist is needed to check the
report and make it an error-free document.
Voice recognition technology is still in a nascent stage.
Career
A
career in medical transcription can be rewarding especially for those who have
a capacity for hard work. The demand for
qualified medical transcriptionists is augmenting day by day.
Course Duration
The
overall duration varies anywhere from 6-12 months, depending on the training
center. Short-term online courses are also
available.
Skills and Abilities
You
can take medical transcription as a career if you have the following basic skills:
Ø Excellent
command over English, including the knowledge of and proper application of
grammar.
Ø The ability to
follow verbal and written instructions.
Ø Basic computer
application skills.
Ø Above average
typing speed.
Ø Ability to work
for long hours.
Ø High level of concentration.
Course Module
A
medical transcription course mainly comprises the following:
Ø Human anatomy, pathophysiology,
and disease processes.
Ø Medical
terminology.
Ø Surgical
procedures.
Ø Pharmacology.
Ø English grammar.
Ø Typing practice.
Advantages
To become a medical transcriptionist, you will not
need an advanced college degree. You just
need to join a good training center from where you will become familiar with
all the aspects related to this promising career. The main advantage of becoming a medical
transcriptionist is that you can work from home also. To start with, all you would need is a
computer, internet connection, a headphone, and a foot pedal. As it is primarily an incentive-based job,
you can earn as much as you want provided that you keep quality as top
priority. There are many
transcriptionists available nowadays, yet excellent ones are relatively hard to
find.
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