Summary

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Medical Transcription is an allied health profession which deals in transcribing and/or editing dictations by physicians and/or other health professionals regarding patient medical record using a voice recognition technology in order to document patient care and facilitate healthcare delivery. It establishes document format, data entry, corrects spelling and medical terminology errors, transcribe/edit documents, and complies with medical-legal policies and procedures.

Medical Transcriptionist

A medical transcriptionist is the one responsible for documenting a person's medical record. To become a qualified medical transcriptionist, one must undergo 18 months to 2 years of specialized training. Special skills of a medical transcriptionist involve mastery in medical terminology, adroitness in editing, and the ability to type while listening.

Due to the increasing demand to document medical records, other countries started to outsource the services of a medical transcriptionist. In the United States, medical transcription business is estimated to worth US$10 to $25 billion annually and growing 15 percent each year.

Duties and Responsibilities

• Transcribes and edits recorded or written material, including operative reports, discharge summaries, patient history and examinations, physician letters and notes, and pharmacy, rehabilitation, autopsy, and x-ray reports.
• Verifies accuracy of patient information such as name and identification number; verifies accuracy of transcription for correct punctuation, grammar, and spelling.
• Maintains logs of medical procedures, incoming dictation, and transcription records.
• Sorts, copies, prepare, assemble, and files records and charts.
• Distributes and collects dictation and transcribed reports; follows up on physicians' missing and/or late dictation.
• Performs quality assurance documentation.
• May maintain disk and disk back up system; may order supplies and report equipment operational problems.
• May collect, tabulate, and generate reports on statistical data, as appropriate.
• May assist with telephone coverage.
• May take minutes of transcription department meetings.
• Performs miscellaneous job-related duties as assigned.

Job Requirements

High school diploma or GED with 1 to 3 years experience directly related to the duties and responsibilities specified.

Knowledge, Skills and Abilities Required

• Knowledge of medical terminology
• Transcription skills.
• Ability to sort, check, count, and verify numbers.
• Skill in the use of operating basic office equipment.
• Ability to follow routine verbal and written instructions.
• Ability to document work in progress.
• Records maintenance skills.

Distinguishing Characteristics

Position requires: a) Transcription, verification, and editing of various recorded and/or manuscripted medical reports, documents, and correspondence b) Maintenance of multiple logs and records c) Sorting, filing, copying, and preparation of files, records, and charts d) Collection and distribution of dictation, to include followup of missing and/or late dictation e) Quality assurance of dictation output

Working Conditions

• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required.
• No or very limited exposure to physical risk.

Reference

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American Association for Medical Transcription

Health | Health sciences | Healthcare occupations