Medical Transcriptionist Education, Schools and Career Overview

To put it in a nutshell, a medical transcriptionist records interactions between patients and providers. These professionals may transcribe office notes, consultation reports, operative (surgery) reports, insurance summaries, radiology reports, pathology reports, autopsies and more. Their role is particularly important in terms of insurance. In many cases, insurance companies won’t reimburse unless they have a complete medical history for the patient. So when a patient is admitted to a hospital, the physician admitting them must submit a record of that patient’s medical history, including previous surgeries, past complications, medications they have taken, and what precipitated their admission to the hospital. The transcriptionists who are assigned these medical histories play a vital role in enabling life-saving surgeries and other procedures to occur.

To learn more about medical transcription, an interview was conducted with Lea Sims, CHDS, AHDI-F, medical transcriptionist of 22 years and Director of Communications and Marketing for the Association for Healthcare Documentation Integrity. Much of this information was gathered from her years of experience in this industry.

The History of Medical Transcriptions

Medical transcription is a field that has evolved over time. There have been medical scribes for almost as long as there have been physicians. Originally, the scribes would actually scrub up and sit in the corner of the operating room with a notepad. It wasn’t until recording devices were invented that a physician was able to dictate notes into a microphone, so a medical transcriptionist could transcribe them later down the line. And with computers, cell phones and the internet, physicians are able to quickly and clearly record their notes right after a procedure and send them directly to a transcriptionist for processing. Transcriptionists are then able to return their documents just as quickly via email or medical software.

As speech recognition software technology (SRT) programs continue to evolve even further, the role of the medical transcriptionist is likely to change and shift yet again. Where might medical transcription be headed in the future? We can't be sure, but we can at least help you understand what this career is like in the present.

Considering speech recognition software, why are medical transcriptionists still used?

Due to the variability in medical language, there continues to be a need for a skilled person to review and edit the documents drafted from transcription software. As of 2014, speech recognition programs are not capable of reliably delivering draft documents with a 98 percent or better accuracy. Even providers who do use SRT programs may still need a medical transcriptionist to edit the draft document for accuracy afterwards.

Some doctors’ offices use electronic medical records (EMRs), which use a point-and-click system of set phrases to build a medical record. These systems can work very well for family practice, general medicine, pediatrics and even radiology, where the terminology is usually repetitive and predictable. However, EMRs can be too restrictive in specialty clinics and acute care facilities, where patient stories can be highly complex and unusual. In these cases a medical transcriptionist may be needed.

Specializations

Historically, professionals in this field have been called "medical transcriptionists" or "medical scribes," but as the profession migrates towards other roles, the title is also shifting. The professional who listens to a dictation and transcribes it word-for-word would still be considered a "transcriptionist." However, a general-purpose employee who works with medical documents in lots of different ways is increasingly being called a "healthcare documentation specialist."

In other situations, a person may use a speech recognition technology engines to create a first draft, then listen to the transcription themselves and make necessary corrections. These individuals work in more of a "medical editor" or "speech recognition editor" role. And "quality assurance coordinators" edit medical transcriptionists' documents, filling in blank spots where the transcriptionist might have been unable to understand a word or phrase.

Some medical transcriptionists may also work in a single field of medicine, doing transcriptions specifically for pathology reports or radiology reports. Because medical terminology can be so complicated, these specialty transcriptionists immerse themselves in the subject, helping them to become quite adept at hearing and understanding the language of their particular specialty.

How to Become a Medical Transcriptionist

Before You Start...

Find an Accredited School

The most important organization for medical transcription is the Association for Healthcare Documentation Integrity (AHDI), the professional association that advocates for and represents medical transcriptionists. This organization accredits medical transcription schools based on its own rigorous evaluation process, assessing whether a school's medical transcription programs are up to the standards of the field.

While you should always be looking to enroll at an accredited school regardless of your major, aspiring medical transcriptionists should specifically be on the lookout for schools that have been accredited by the AHDI. As of 2014, there are 18 AHDI-approved schools for medical transcription.

Hone Your Typing Skills

Many medical transcription training programs have pre-screening tests to check that applicants have suitable grammar, punctuation and overall language skills, as well as a fairly rapid typing speed. As of 2014, the standard typing speed was 45-50gpm (gross words per minute). If you're concerned about your ability to meet these numbers, it's never a bad idea to take a class or practice on your own to improve your typing, grammar and/or punctuation skills.

Degree Programs

Most medical transcription education programs are certificate-level, although some are at the associate degree level instead. While earning a degree or certificate is not required for practicing in this field, transcriptionists who have not earned either may have a difficult time earning a position, since demonstrable productivity and speed are important in this field.

Classes in a medical transcription program may include: anatomy, physiology, medical terminology, disease processes, fundamentals of laboratory medicine, pharmacology, English, grammar, punctuation and medical transcription style. "Transcription style" refers to the way clinical information should be expressed in the medical record. Courses in this subject should include information on when to use Roman numerals versus an Arabic number, how cancer stages are expressed, how to express ratio statements, etc. They should also cover the field's style manual -- "The Book of Style for Medical Transcription."

Medical transcription certificate programs generally take anywhere between 10 months to one year to complete, and typically focus on the fundamental skills used as a medical transcriptionist.

Associate degree programs in medical assisting usually focus on developing a thorough understanding of medical terminology, pharmacology, anatomy, and physiology; developing strong proofreading and editing skills; and perhaps most importantly, improving typing speed and accuracy using competency software. These programs may also require communication and mathematics courses, as part of preparing students to sit for their AHDI certification exams: the RHDS and the CHDS.

Online Schools

There are medical transcription programs both in online and traditional on-campus formats available.

Certifications

Although certification is not necessary, it may prove to be an advantage when seeking a job. The BLS states that certification is available through the AHDI, which offers two types of certification: the RHDS and the CHDS.

• The level one credential is the Registered Healthcare Documentation Specialist (RHDS), formerly known as the RMT (registered medical transcriptionist). This is the entry-to-practice credential. It is also the credential for transcriptionists working in a single specialty, like cardiology or radiology. As long as you have graduated from an approved transcription program, you should be able to sit for the RHDS exam.
• The level two credential is the Certified Healthcare Documentation Specialist (CHDS), formerly known as the CMT (certified medical transcriptionist). To sit for this exam, a transcriptionist must demonstrate a minimum of two years’ experience working in acute care (hospital-level documentation). These exams are administered through the AHDI and offered through testing centers around the world.

The exams consist of two parts. The first part includes 120 multiple-choice questions that test anatomy and physiology, medical terminology, disease processes, styles and standards, grammar and punctuation. The second part of the exam is a practical portion that involves transcribing excerpts of information and editing incorrect portions of excerpts. The exam generally takes three to four hours to complete.

Continuing Education

The RHDS credential does not include continuing education requirements, but the CHDS credential does. The goal would be for most RHDS to sit for the CHDS exam after they have met their requirement of having two years of hospital documentation experience. There is an RHDS recredentialing course to maintain the RHDS if, after three years, a person decides not to sit for the CHDS.

To maintain the CHDS credential, 30 or more continuing education credits are required within a three-year period. CHDS can earn continuing education through national, state/regional, and local educational conferences and symposia as well as through online courses, taking quizzes after reading credit-worthy articles in industry publications, and even watching videos through the Discovery Health Channel.

Skills and Qualities

Several of the skills that are useful to a career in medical transcription are unlikely to surprise you. For example, a strong affinity for language and a good interpretive ear is important. Being willing and able to meet strict deadlines is often necessary. Typing skills and a basic understanding of computers are a key part of the job's responsibilities. Having an interest in healthcare and medicine is also useful for maintaining interest and dedication in the field.

However, there is another element to this career. Medical transcription lends itself to a home-based work setup because it is an easily portable skill that requires little equipment. As such, many of the people in this industry work from home, and a significant portion of those workers are freelance contractors. (For this reason, medical transcription can be appealing for stay-at-home parents or constantly-moving military spouses.) It is vital for transcriptionists who work remotely to be self-disciplined, have a strong work ethic, and have the ability to perform in a production-based environment.

Some hospitals employ transcriptionists to work on the scene, transcribing emergencies or stat reports, which need to be completed immediately in order to inform the hospital's decisions about how to provide care. Transcriptionists in these careers should be ready to work quickly and have a good sense of priorities in case they have multiple urgent assignments at one time. Communication skills are also important for working with other hospital employees, such as the practicing physicians and the medical records director.

Career Outlook and Salary Information

As described above, many medical transcriptionists work from home -- either as members of a medical transcription service or as freelance contractors -- and many others find employment on-site in hospitals. However, plenty of medical transcriptionists move into the editing side of the industry, or into quality assurance specialist positions. Others may become teachers or professors, educating others who are looking to enter the field by teaching courses for medical transcription certificate or degree programs.

Medical transcriptionists can be paid in different ways. Some transcriptionists are paid on a per-line basis, or a per-document basis. Others are paid an hourly rate, while still others are paid an annual salary. In some cases, an employer may even pay a medical transcriptionist to be available during a designated window of time. Transcriptionists should talk to their employers to arrange a setup they are comfortable with for their situation.

Professional and Academic Resources for Medical Transcriptionists

The Association for Healthcare Documentation Integrity (AHDI) is the professional organization for medical transcriptionists. This organization sets standards for the profession by approving medical transcription education programs and by offering a first- and second-level credentialing process (RHDS and CHDS). The association actively lobbies and advocates for the role of medical transcription in healthcare delivery and the electronic health records (EHR), sets standards of practice for the sector, and offers information, resources and educational programming for both its members and the industry as a whole. Membership for the professional medical transcriptionist can mean access to all of these resources, as well as the opportunity for networking with industry employers, vendors, peers and educators.

Sources

1. Interview with Lea Sims, conducted in January 2014
2. Medical Transcriptionists, Bureau of Labor Statistics, Occupational Employment Statistics, May 2014, http://www.bls.gov/oes/current/oes319094.htm
3. Medical Transcriptionists, Bureau of Labor Statistics, Occupational Outlook Handbook, July 2018, https://www.bls.gov/ooh/healthcare/medical-transcriptionists.htm