Medical Transcription is the process of transcribing or converting recorded dictation of physicians or other healthcare professionals into written text. It deals with converting patient’s reports and records dictated by doctors in to an electronic or paper format.
How it proceeds-
When a patient visits a doctor, the doctor spends some time with the patient discussing his/her problems and past medical record, if any. First, the doctor performs a physical examination of the patient and may request for some diagnostic tests. From that report, the doctor makes a diagnosis and plans about the treatment for the patient, which is discussed and explained to the patient with specific instructions such as when and how to take medicines and after how many days he has to come for check-up. Then, the patient leaves the office, and the doctor uses a voice-recording device to record the information regarding the patient and his/her problem. This information may be recorded in a cassette recorder or into telephone. Then this recorded file is sent to the professional medical transcriptionist for transcription. Now it is the duty of the transcriptionist to listen the recorded file carefully and transcribes it into required format for medical record. When the same patient will come to the doctor for the second time, the doctor asks for the medical record that contains all reports from the previous encounter. After examining the patient and the record, the doctor may change medicines.
Therefore, it is very important to transcribe the medical record without any mistake. It should be properly formatted, edited and reviewed before sending the final copy. If a medical transcriptionist typed a wrong medication or wrong diagnosis, the patient might be at risk. It is both the doctor and the transcriptionist are equally important to make a transcribed document accurate and correct. While recording, the doctor should speak slowly the name of the disease and medication prescribed. On the other hand, the MT should hear the record correctly, should have knowledge of medical terminologies and should read it three/four times before the final edition. Medical transcriptionists are never permitted to guess in transcription.
Medical transcription is challenging as well as rewarding. Medical transcriptionists are an integral and important part of health care industry. Medicines are constantly changing. New equipment, new medical devices and new medications are coming to market almost daily. Therefore, medical transcriptionists should be creative enough to find new words and terminologies in medicines.