Doctors are well-known for their messy handwriting. So how are the records at hospitals and other medical facilities kept accurate and legible? Through the work of medical transcriptionists. Transcriptionists use computers to transcribe medical information provided by doctors and other health care professionals. The records they produce become permanent medical records.
Transcriptionists listen to and transcribe medical information that doctors dictate into voice recorders. They also transcribe rough notes from medical reports and other written information produced by doctors. This can include patient histories, consultation reports, physical examination reports, operative reports, discharge summaries, autopsy reports, and referral letters.
The transcription process requires a strong familiarity with medical terminology. Many medical terms look or sound very similar, and transcriptionists need to be sure they are transcribing the information correctly. If they’re not sure about a word, they research it in medical textbooks or on the Internet before recording it in the transcribed record.
Transcriptionists should also be able to spot mistakes made by doctors. For example, a transcriptionist may notice that a doctor has been inconsistent with the name of a particular medication throughout a report. The transcriptionist would then check with the doctor to find out whether or not the information is correct. Because these records may affect the future care given to a patient, accuracy is essential.
Once they have transcribed the material, transcriptionists are responsible for proofreading the record they have produced. This involves checking for any grammatical errors or spelling mistakes. The transcriptionist also edits the record for clarity—it must make sense to anybody who reads it. However, he or she must be careful not to change the meaning of the information provided by the doctor.
The completed record is then reviewed by the doctor. If any mistakes are found, the transcriptionist makes the necessary corrections. When the record has been approved by the doctor it becomes part of the patient’s medical file.
Transcriptionists who work in medical clinics and doctors’ offices may have additional duties besides transcribing. For example, they may answer the phone, schedule appointments, welcome and check-in patients, and look after the mail.
NOC Code: 1244