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Medical transcriptionists (MTs) are sometimes referred to as healthcare documentation specialists. Their main role is listening to medical voice recordings from healthcare workers and medical practitioners and then converting them to written reports. They are involved in reviewing and editing medical documents using speech recognition technology.
MTs also interpret medical terminologies and abbreviations when preparing for discharge summaries and medical histories. It is an essential profession in allied healthcare as most healthcare facilities will need them for creating patient reports based on medical practitioners’ assessments.
If this sounds like the career path you would like to embark on, it is important to know what the profession is all about, including the education and certification requirements. You might also be interested in knowing what you’ll earn and the job prospects. This article highlights MTs job description, the procedure for becoming one, and their salary and job outlook.
Medical Transcriptionist Job Description
Medical transcription is an allied healthcare profession that deals with the process of transcribing voice-recorded reports by medical practitioners. The recordings are typically dictated by physicians, nurses and other healthcare professionals. The medical reports can be in a variety of forms, including notes, voice files, or any other spoken material. They could also be dictated over the phone or uploaded digitally through the internet or via smartphone applications.
Medical transcriptionists edit dictated reports, notes, and procedures in an electronic format to create files that represent the patients’ treatment history. Healthcare practitioners usually dictate what they have done after performing medical procedures on patients, and then the medical practitioners (MTs) transcribe the oral dictation and edit reports presented to them that may have gone through speech recognition software.
Up-to-date and confidential patient information is typically converted to a written text document by the MT. The text can be printed and placed in the patient records and kept in an electronic format. Medical transcription is typically performed by MTs employed in hospitals or who work at home as telecommuters for the hospitals.
Independent contractors and telecommuting employees can also transcribe off-site or under contract to a clinic, hospital, physician group, or any other healthcare provider. MTs can also work directly for the provider of services, such as doctors, either on-site or telecommuting as contractors or employees.
Hospital facilities prefer electronic storage of the medical records due to the big volume of patient records and the associated paperwork. Electronic health records (EHRs) store medical records and are databases that provide instant access to the providers or hospital departments regarding the patient’s medical history, notation of previous or present medications, and notification to patient allergies regardless of the geographical location or distance.
Medical transcription entails performing document typing and formatting under an established criterion and transcribing spoken word of the patient’s care information into a written and easily readable format. This means that medical transcriptionists should observe accuracy in writing and the final document should not have spelling errors.
Medical transcriptionists should also correct medical terminologies or dictation errors. They edit the transcribed documents, print, and return them in a timely fashion. All transcription that MTs produce must comply with micro-legal concerns, policies, procedures, and laws under patient confidentiality.
Medical Transcriptionist Duties And Responsibilities
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- Following up with the healthcare providers to ensure that the medical reports are accurate and serve the purpose they were intended for
- Interpreting and transcribing the dictation into examination and diagnosis notes
- Interpreting and transcribing dictation into patient history, referral letters, operative reports, and discharge summaries among other patient documents
- Listening to the medical recordings, such as a doctor’s dictation among other healthcare workers
- Reviewing and editing drafts that have been prepared using speech recognition software and ensuring that the transcription is complete and correct
- Entering medical reports into electronic health records (EHR) systems
- Performing quality improvement audits
- Translating medical jargon and abbreviations into the understandable and appropriate long form
- Identifying errors, inconsistencies, and missing information within a medical report that could otherwise compromise the provision of patient care
- Submitting healthcare records for physicians to approve
- Ensuring that they observe patient confidentiality guidelines and legal documentation requirements
Traditionally, medical transcriptionists used audio playback equipment so they could listen to physician dictations and provide the transcribed reports. However, due to technological advancements, they use speech recognition software which makes it easier for them to do their job.
Speech recognition software is specialized software that automatically prepares an initial draft of the medical report. The medical transcriptionist then listens to the voice file and reviews the draft for accuracy and consistency, identifying all the errors and edits them as required. The transcriptionists typically use word-processing or any other software to prepare the transcripts along with the required reference materials.
Transcriptionists must be familiar with medical terminology, anatomy and physiology, pharmacology, diagnostic procedures, and treatment assessments. Their capability of understanding what the medical practitioner has recorded and correctly transcribing that information and identifying inaccuracies and inconsistencies in the final transcript is critical to reducing chances that patients will get ineffective or even harmful treatments and medications. They must also be familiar with EHR systems and may be involved in other duties, such as greeting patients and answering phones.
How To Become A Medical Transcriptionist
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Medical transcriptionists need post-secondary education in medical transcription. This is typically offered by vocational schools, distance-learning programs, and community colleges. The programs take about a year, but there are also the associate’s degree programs.
The programs include coursework in risk management, medical terminology, anatomy, legal issues associated with healthcare documentation, and English grammar and punctuation. Most of the programs include supervised on-the-job experience. Some transcriptionists with previous experience such as medical secretary or nursing assistants become proficient via refresher training and courses.
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Even though certification is not needed, some transcriptionists choose to be certified. The Association for Healthcare Documentation Integrity offers certifications in Registered Healthcare Documentation Specialist (RHDS) and Certified Healthcare Documentation Specialist (CHDS). Both certifications require MTs to pass an exam but will require continued education or periodic testing.
RHDS certification is for recent graduates, particularly those with two years of experience and who work in a single specialty environment such as a doctor’s office or a clinic. CHDS certification is for medical transcriptionists who hold the RHDS designation. CHDS candidates should also have at least two years of acute care experience, including experience handling dictation in various medical specialties. For you to maintain certification, complete continuing education every three years.
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- Computer skills
- Listening skills
- Time-management skills
- Critical thinking skills
- Writing skills
Salary And Job Outlook
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According to the BLS, the median annual average wage for medical transcriptionists was $35,250 in May 2017. The lowest 10% earned less than $21,670 but the highest 10% earned over $51,410.
The median annual salaries in the various top industries were:
- Medical and diagnostic laboratories: approximately $41,540
- Hospitals; state, local, and private: approximately $38,910
- Offices of physicians: approximately $35,540
- Administrative and support services: approximately $28,300
However, some transcriptionists are paid based on the volume of transcription they produce. Others are paid on an hourly rate or an annual salary. Most of the transcriptionists work full time although about a third of them worked part-time in 2016. Transcriptionists who work from home may work late at night as they have flexibility in determining their schedules. Their work can be stressful since they have to ensure the accuracy of medical reports with quick turnaround time.
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The BLS reported that there were 57,400 jobs for medical transcriptionists in 2016. However, based on projections, there will be a decline of 3% in the number of jobs between 2016 and 2026. This implies that in the same period, about 1,900 jobs will be cut off. This is attributed to technological advancements, which have changed the way medical transcription is done.
The aging population and increased rates of chronic conditions will increase the demand for healthcare services, which will lead to a growing number of medical tests and procedures, all of which will need transcription. However, speech recognition software and EHRs allow physicians to create documentation straight away, which reduces the need for MTs. As healthcare providers seek cost cuts, some will contract transcription services. They may also outsource such services from other countries, which will reduce domestic employment.
MTs are tasked with following up with the healthcare providers to ensure that the medical reports are accurate, interpreting and transcribing voice data into examination and diagnosis notes, patient history, referral letters, operative reports, and discharge summaries, reviewing and editing report drafts and ensuring that the transcription is complete, correct, and consistent in style.
Medical transcriptionists are also involved with entering medical reports into EHRs, performing quality improvement audits, translating medical jargon and abbreviations, and identifying errors, inconsistencies, and missing information within a medical report.
Due to technological advancements, transcriptionists use speech recognition software which makes it easier for them to do their job. Transcriptionists must be familiar with medical terminology, anatomy and physiology, pharmacology, diagnostic procedures, and treatment assessments.
Medical transcriptionists need post-secondary education in medical transcription but can be certified by the Association for Healthcare Documentation Integrity, which offers RHDS and CHDS certification. The average salary is about $35,250, but jobs are anticipated to decline due to technological advancements. We hope that this article has adequately addressed what MTs do, how to become one, and their salary and job outlook.