Medical Transcription: Converting Voice Files to Medical Information

By Kelvin A Smith

All clinics, hospitals, nursing homes and physicians' offices produce reports, results of tests, etc. This is called medical transcription and it also encompasses office chart notes, letters, initial office evaluations, history and physical examinations. Through this documentation, information can be given to insurance companies in an orderly manner. It is important to keep in mind that these records should be organized in a sequential manner. They should also include the following:

• History of the patient
• Doctor's evaluation
• The illness
• The objective of the treatment
• Prescriptions
• Results after taking the prescribed medicine

Forms
Medical transcription can be stored in two forms: digitally or in printed form. At times, it is stored digitally as well as in the printed format. Whichever method of storage is used, transcriptions are hospital property and stored in files.
In the current era of modern technology, medical transcripts are usually stored on computers via the internet. Not only is the internet a component of medical transcription but voice recognition as well.
Transcription incorporates data dictated by doctors as well as a variety of other things such as:

• Patient history (which includes physical and mental reports)
• Clinical/Office notes
• Reports related to operations and their results
• Consultation reports
• Discharge summaries
• Evaluative reports
• X-ray/Test results
• Pathology reports

Since doctors themselves are very busy they usually hire people to organize their transcription records.
Who Carries Out A Transcription?
As mentioned earlier, doctors are busy and usually hire people to carry out their transcription needs. Such a person is known as a transcriber. A transcriber or transcriptionist is the person who translates the transcribed notes into a type written format. The confidential information of any given patient is given to the transcriptionist who converts it to a legible, written format. The transcriptionist is dictated by the doctor via a variety of methods which include dictation through the tape, digital system or even voice files. These are produced through either a digital recorder (linked to a digital phone system which the dictator uses) or through the telephone.
Tools/Skills
In order to be a transcriptionist the following are essential and these equipment should always be of good quality:

• Earphones
• Foot pedal
• Stop control
• Word processing program

With respect to the transcriber's personal skills, the following are very important in a transcriber-

• Listening/language proficiency
• Speech recognition
• Computer skills
• good grammar/punctuation
• Knowledge of medical terms and anatomy
• Adequate knowledge of diagnostic procedures and pharmacology
• Knowledge of Assessment of Treatment
• Knowledge of Legislative and ethical areas of medical reports
• Proofreading capability (which involves editing to clarify and rectify mistakes/inconsistencies)

After the transcriber has proofread the data, it is sent to a proofreader for any grammar/clarity issues. After the information has been transcribed, it is sent to the doctor/dictator who goes through it to authenticate it and add his signature. After the dictator gives the go-ahead, the document is incorporated into the patient's permanent record file. At times, the process is shortened due to an audio typing service. Such a service does away with the need for a dictator to dictate all the information.
How It Takes Place
Transcription involves three steps. These are-

1. The preliminary step of transcription starts when a patient visits the doctor. The doctor discusses medical history and diagnosis with the patient. The doctor may also ask for additional tests or diagnostic studies. The doctor then discusses his diagnosis with the patient.
2. After the doctor/patient discussion, the doctor physically records the information via a voice recording device. The file is changed to a WAVE format and sent to foreign transcription centres via satellites. The transcriber then listens to the file and transcribes it and sends it for inspection to a quality control person who corrects any discrepancies and requisite corrections are made.
3. Once the transcribed report has been approved, it is sent to the doctor in the form of a word file. During transmission the document should be accurately formatted, edited and reviewed as a medical transcription document. Wrong diagnosis/medication would result in dire consequences for the patient. Thus, it is important the doctor himself reviews the document.

It is both the doctor and the transcriptionist's responsibility to ensure that the transcribed document is up to the mark.
Potential Challenges
The transcribing profession may seem to be easy but it has many challenges. The transcriptionist needs to keep up with an ever-changing information base, as there are new medications and procedures every day, while medical terminology is also constantly changing. As such, this profession requires excellent audio, visual, tactile and cognitive coordination. The transcriptionist needs to be diligent, enthusiastic and dedicated.
The language if the transcript is also important. The decorum of language should be kept up which gives the report more authority.

The business of medical transcription service is very lucrative. If you need audio typing service for your firm, you can contact us.

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