What Medical Transcriptionists Do
Medical transcriptionists listen to voice recordings that physicians and other healthcare professionals make and convert them into written reports. They may also review and edit medical documents created using speech recognition technology. Transcriptionists interpret medical terminology and abbreviations in preparing patients’ medical histories, discharge summaries, and other documents.
Medical transcriptionists typically do the following:
- Listen to the recorded dictation of a doctor or other healthcare professional
- Transcribe and interpret the dictation into diagnostic test results, operative reports, referral letters, and other documents
- Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and has a consistent style
- Translate medical abbreviations and jargon into the appropriate long form
- Identify inconsistencies, errors, and missing information within a report that could compromise patient care
- Follow up with the healthcare provider to ensure the accuracy of the reports
- Submit health records for physicians to approve
- Follow patient confidentiality guidelines and legal documentation requirements
- Enter medical reports into electronic health records systems
- Perform quality improvement audits
Medical transcriptionists use audio playback equipment or software that is connected to their computer. This equipment often includes a headset and foot pedal, which are used to control the recording playback speed. They use word-processing and other specialized software, as well as medical reference materials, as needed.
Technological advances have changed the way some medical transcription is done. In the past, medical transcriptionists would listen to an entire dictation to produce a transcribed report. While many transcriptionists still perform these traditional transcription services, many are taking on additional roles. Today, many medical documents are prepared with the use of speech recognition technology, in which specialized software automatically prepares an initial draft of a report. The transcriptionist then reviews the draft for accuracy, identifying any errors, and editing the report, when necessary.
To do their work, medical transcriptionists must become familiar with medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. Their ability to understand what the health professional has recorded, correctly transcribe that information, and identify any inaccuracies in the transcript is critical to reducing the chance that patients will get ineffective or even harmful treatments. They are part of the team that ensures high-quality patient care.
Transcriptionists may need to be familiar with electronic health records (EHR) systems. They may need to enter reports, create templates, help develop documentation policies, and train physicians on how to use EHR systems.
Medical transcriptionists who work in doctors’ offices may have other duties, such as answering phones and greeting patients.
How to Become a Medical Transcriptionist
Medical transcriptionists typically need postsecondary training. Prospective medical transcriptionists must have an understanding of medical terminology, anatomy and physiology, grammar, and word-processing software.
Employers prefer to hire transcriptionists who have completed postsecondary training in medical transcription, which is offered by many vocational schools, community colleges, and distance-learning programs.
A 1-year certificate program or 2-year associate’s degree normally includes coursework in anatomy, medical terminology, risk management, legal issues relating to healthcare documentation, and English grammar and punctuation. 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.
Licenses, Certifications, and Registrations
Although certification is not required, some medical transcriptionists choose to become certified. The Association for Healthcare Documentation Integrity offers the Registered Healthcare Documentation Specialist (RHDS) and the Certified Healthcare Documentation Specialist (CHDS) certifications.
The RHDS certification, formerly known as the Registered Medical Transcriptionist (RMT), is for recent graduates with less than 2 years of experience and who work in a single specialty environment, such as a clinic or a doctor’s office.
The CHDS certification, formerly known as the Certified Medical Transcriptionist (CMT), is for transcriptionists who have at least 2 years of experience and those who handle dictation in several medical specialties.
Both certifications require passing an exam and periodic retesting or continuing education. While the RMT and the CMT exams are no longer offered, transcriptionists who hold those certifications may choose to maintain them or to complete a bridge course to earn the RHDS or the CHDS.
Computer skills. Medical transcriptionists must be comfortable using computers and word-processing software, because those tools are an essential part of their jobs. Transcriptionists may also need to know how to operate electronic health records (EHR) systems.
Critical-thinking skills. Transcriptionists must be able to assess medical reports and spot any inaccuracies and inconsistencies in finished drafts. They must also be able to think critically when doing research to find the information that they need and to ensure that sources are both accurate and reliable.
Listening skills. Transcriptionists must listen carefully to dictation from physicians. They must be able to hear and interpret the intended meaning of the medical report.
Time-management skills. Because dictation must be done quickly, medical transcriptionists must be comfortable working under short deadlines.
Writing skills. Medical transcriptionists need a good understanding of the English language and grammar.
Percent change in employment, projected 2012-22
- Other healthcare support occupations
- Total, all occupations
- Medical transcriptionists
Employment of medical transcriptionists is projected to grow 8 percent from 2012 to 2022, about as fast as the average for all occupations.
Federal health legislation will expand the number of patients who have access to health insurance, increasing patient access to medical care. The increasing volume of healthcare services will result in a growing number of medical tests and procedures, all of which will require transcription.
At the same time, technological advances have changed the way medical transcription is done. Speech recognition software and other technological advances may make transcriptionists more productive and, therefore, limit employment growth.
In addition, as healthcare providers seek to cut costs, some have hired transcription services in other countries. However, concerns about patient confidentiality and data security suggest a continued need for transcriptionists within the United States.
Prospects should be good for transcriptionists with formal education and for those with experience in electronic health records (EHR) management, training, and quality assessment. Job opportunities will stem from transcriptionists who retire over the next decade, creating opportunities for new transcriptionists.
|Occupational Title||SOC Code||Employment, 2012||Projected Employment, 2022||Change, 2012-22||Employment by Industry|
SOURCE: U.S. Bureau of Labor Statistics, Employment Projections program
|Occupation||Description||Entry-Level Education||2012 Median Pay|
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