Medical Transcription Jobs

By an allied health world contributing writer
Published: February 28th, 2010

What is the job of a medical transcriptionist?

A medical transcriptionist captures and records any health care encounter that a patient has with a provider in a permanent, edited and legally-sound way. The physician dictates into a digital capturing device or a phone that is connected to a dictation system in Medical Transcription Jobs

his/her clinic. The transcriptionist is responsible for listening to the physician’s dictation and recording it into a patient’s permanent record. Sixty percent of all health information in the United States is captured through the dictation/ transcription process. This means that that greatest portion of health care encounter information occurring either in a private practice or hospital setting involves a transcriptionist’s direct involvement in ensuring that the dictation has been captured accurately and becomes part of the patient’s permanent health care record. Types of encounters in the office setting may include a first time visit in a physician’s office, follow up visits, and consultation with a specialist. At the hospital level encounters can include the history, operative procedure, radiology reports, and discharge summary. Pathology is another area medical transcriptionists are needed to capture specimen descriptions and autopsies.

How will the role of a medical transcriptionist evolve and change with time?

With some offices now using voice recognition technology and electronic medical records (EMRs), there is still a need for medical transcriptionists to edit documents transcribed by the computer. These automated transcriptions cannot be relied on as fully accurate so a human element is necessary. Therefore while the field of medical transcription is alive and thriving, the role of the medical transcriptionist will likely evolve over time. Medical transcriptionists will have more of a hybrid role of editing documents and tagging them important words and phrases for searchability and research purposes.

Also, currently the role of the medical transcriptionist and medical coder are separate but these two may become blended roles in the future. In this case one hybrid role would capture the narrative and code it as it is being captured. Medical coding involves assigning a classification code for insurance reimbursement to the primary diagnosis, procedures, and treatments of the patient. Insurance companies then read those codes to determine what reimbursement will be given for a particular procedure.

Learn more about medical transcription careers.

What types of documents do transcriptionist transcribe?

Transcriptionists transcribe office notes, consultation reports, consultation letters, history and physical examinations, operative (surgery) reports, insurance summaries, radiology reports, pathology reports, and autopsies. Because hospitals are accredited by The Joint Commission, which is the accrediting body for acute care facilities, part of their requirement for continuing accreditation is record documentation. Every procedure performed on a patient in a hospital has to be documented. Insurance companies to a large degree drive that requirement because they won’t reimburse in many instances without a copy of those procedures. So when a patient is admitted to the hospital, before anyone can touch them, the physician admitting them must dictate and have a record of that patient’s past medical history including any surgeries they’ve had previously, past complications, medications they have taken, and what precipitated their admission to the hospital. The doctor then must have that information dictated, documented, and included in the patient’s charts so that any specialist who looks at the patient has that patient’s health history and physical available. The transcriptionists who are assigned these medical histories must have incredibly quick turn around time so as not to slow down an impending surgery or procedure.

What are tagging and data abstracting?

Tagging and data abstracting are relatively new roles that are emerging to help sort and search for certain terms within a document. Currently most records are like image files in a hospital system where queries cannot be run on them. Tagging involves coding specific words and phrases in a narrative report so that the data can be searched for statistical and research purposes. For example, tagging will make it possible for a health care provider to search for all the patients who have had a certain reaction to a certain type of drug by running queries on the data. Another example of where tagging is useful is when codifying information in a document to help with clinical decision-making. For instance, if a physician mentions in a dictated narrative that a patient has a history of smoking, the word “smoking” could be tagged so when the physician reads the report he sees it is necessary to council the patient on smoking cessation. Data abstracting is the process of searching for data by certain tagged words and phrases.