The
Candidate should give 2 years of commitment (Mandatory).
After completion of 2yrs home base transmission is
available.
O.K.
now let’s look at the story – what is medical transcription
- What does a medical transcriptionist do?
In the broadest sense, medical transcription is the act of translating from oral to written form (on paper or electronically) the record of a person's encounter with a healthcare professional. Medical transcriptionists (MTs) are specialists in medical language and healthcare documentation. They interpret and transcribe dictation by physicians and other healthcare professionals regarding patient assessment, workup, therapeutic procedures, clinical course, diagnosis, prognosis, etc., editing dictated material for grammar and clarity as necessary and appropriate.
- What personal characteristics do I need in order to become a medical transcriptionist?
You need excellent English grammar skills, as well as a compelling interest in and knowledge of continuous new medical equipment and procedures, scientific updates, federally approved pharmaceutical products, etc., which are reflected in medical language. You need superior resource skills. You need hand-eye coordination and keen listening skills. You need reasonable computer keyboarding skills and sit for long hours, often in a high-pressure environment.
Medical documents often are requested to be expedited copy. A high level of concentration for extended periods of time is also important. Medical transcription requires a practical knowledge of medical language relating to anatomy, physiology, disease processes, pharmacology, laboratory medicine, and the internal organization of medical reports. A transcriptionist is a medical language specialist who must be aware of standards and requirements that apply to the health record, as well as the legal significance of medical transcripts.
Traditional reports of patient care take many forms including histories and physical examinations, progress reports, emergency room notes, specialty consultations, operative reports, diagnostic and laboratory findings, discharge summaries, clinic notes, referral letters, and an array of documentation spanning more than 60 medical specialties. They are frequently dictated by healthcare providers for whom English is a 2nd (3rd, or greater) language.
- Where do medical transcriptionists work?
Medical transcriptionists use their talents in a variety of healthcare settings, including doctors' offices, public and private hospitals, teaching hospitals, medical schools, medical transcription businesses, clinics, laboratories, pathology and radiology departments, insurance companies, medical libraries, government medical facilities, rehabilitation centers, legal offices, research centers, veterinary medical facilities, and associations representing the healthcare industry wherever dictation for the purpose of healthcare documentation requires transcription. Many MTs work from their homes as independent contractors, subcontractors, or home-based employees.
- Who do medical transcriptionists work for?
Medical transcriptionists work with physicians and surgeons in multiple specialties. They work with pharmacists, therapists, technicians, nurses, dietitians, social workers, psychologists, and other medical personnel. All of these healthcare providers rely on information that is received, accurately documented, and disseminated by the medical transcriptionist.
Qualified medical transcriptionists who wish to expand their professional responsibilities may become quality assurance specialists, editors, supervisors.
Experienced medical transcriptionists may become teachers, working in schools and colleges to educate future medical transcription professionals as managers, department heads, or owners of medical transcription businesses.
complete story
Medical transcription
Medical transcription, also known as MT, is an allied health profession, which deals in the process
of transcription, or converting voice-recorded reports
as dictated by physicians and/or other healthcare professionals, into text
format.
History
Evolution of transcription dates back to the 1960s.
The method was designed to assist in the manufacturing process. The first
transcription that was developed in this process was MRP, which is the acronym
for Manufacturing Resource Planning, in 1975. This was followed by another advanced
version namely MRP2. But none of them yielded the benefit of medical
transcription.
However, transcription
equipment has changed from manual typewriters to electric
typewriters to word processors to computers and from
plastic disks and magnetic belts to cassettes and endless loops and digital
recordings. Today, speech recognition (SR), also known as continuous speech
recognition (CSR), is increasingly being used, with medical transcriptionists
and or "editors" providing supplemental editorial services, although
there are occasional instances where SR fully replaces the MT. Natural-language
processing takes "automatic" transcription a step further, providing
an interpretive function that speech recognition alone does not provide
(although MTs do).
In the past, these medical
reports consisted of very abbreviated handwritten notes that were added in the
patient's file for interpretation by the primary physician responsible for the
treatment. Ultimately, this mess of handwritten notes and typed reports were
consolidated into a single patient file and physically stored along with
thousands of other patient records in a wall of filing cabinets in the medical
records department. Whenever the need arose to review the records of a specific
patient, the patient's file would be retrieved from the filing cabinet and
delivered to the requesting physician. To enhance this manual process, many
medical record documents were produced in duplicate or triplicate by means of
carbon copy.
In recent years, medical
records have changed considerably. Although many physicians and hospitals still
maintain paper records, there is a drive for electronic records. Filing
cabinets are giving way to desktop computers connected to powerful servers,
where patient records are processed and archived digitally. This digital format
allows for immediate remote access by any physician who is authorized to review
the patient information. Reports are stored electronically and printed
selectively as the need arises. Many MTs now utilize personal computers with
electronic references and use the Internet not only for web resources but also
as a working platform. Technology has gotten so sophisticated that MT services
and MT departments work closely with programmers and information systems (IS)
staff to stream in voice and accomplish seamless data transfers through network
interfaces. In fact, many healthcare providers today are enjoying the benefits
of handheld PCs or personal data assistants (PDAs) and are now utilizing
software on them for dictation.
Overview
Pertinent up-to-date,
confidential patient information is converted to a written text document by a
medical transcriptionist (MT). This text may be printed and placed in the
patient's record and/or retained only in its electronic format. Medical
transcription can be performed by MTs who are employees in a hospital or who work at home as
telecommuting employees for the hospital; by MTs
working as telecommuting employees or independent contractors for an outsourced
service that performs the work offsite under contract to a hospital, clinic,
physician group or other healthcare provider; or by MTs working directly for
the providers of service (doctors or their group practices) either onsite or
telecommuting as employees or contractors. Hospital facilities often prefer
electronic storage of medical records due to the sheer volume of hospital
patients and the accompanying paperwork. The electronic storage in their database gives immediate access to
subsequent departments or providers regarding the patient's care to date,
notation of previous or present medications, notification of allergies, and
establishes a history on the patient to facilitate healthcare delivery regardless of
geographical distance or location.
The term transcript or
"report" as it is more commonly called, is used as the name of the
document (electronic or physical hard copy) which results from the medical
transcription process, normally in reference to the healthcare professional's
specific encounter with a patient on a specific date of service. This report is
referred to by many as a "medical record". Each specific transcribed
record or report, with its own specific date of service, is then merged and
becomes part of the larger patient record commonly known as the patient's
medical history. This record is often called the patient's chart in a hospital
setting.
Medical transcription
encompasses the MT, performing document typing and formatting functions
according to an established criteria or format, transcribing the spoken word of
the patient's care information into a written, easily readable form. MT
requires correct spelling of all terms and words, (occasionally) correcting
medical terminology or dictation errors. MTs also edit the transcribed
documents, print or return the completed documents in a timely fashion. All
transcription reports must comply with medico-legal concerns, policies and procedures,
and laws under patient confidentiality.
In transcribing directly
for a doctor or a group of physicians, there
are specific formats and report types used, dependent on that doctor's
speciality of practice, although history and physical exams or consults are
mainly utilized. In most of the off-hospital sites, independent medical
practices perform consultations as a second opinion, pre-surgical exams, and as
IMEs (Independent Medical Examinations) for liability insurance or disability claims. Some private
practice family doctors choose not to utilize a medical transcriptionist,
preferring to keep their patient's records in a handwritten format, although
this is not true of all family practitioners.
Currently, a growing number
of medical providers send their dictation by digital voice files, utilizing a
method of transcription called speech or voice recognition. Speech recognition
is still a nascent technology that loses much in translation. For dictators to
utilize the software, they must first train the program to recognize their
spoken words. Dictation is read into the database and the program continuously
"learns" the spoken words and phrases.
Poor speech habits and
other problems such as heavy foreign accents and mumbling complicate the
process for both the MT and the recognition software. An MT can
"flag" such a report as unintelligible, but the recognition software
will transcribe the unintelligible word(s) from the existing database of
"learned" language. The result is often a "word salad" or
missing text. Thresholds can be set to reject a bad report and return it for
standard dictation, but these settings are arbitrary. Below a set percentage
rate, the word salad passes for actual dictation. The MT simultaneously listens,
reads and "edits" the correct version. Every word must be confirmed
in this process. The downside of the technology is when the time spent in this
process cancels out the benefits. The quality of recognition can range from
excellent to poor, with whole words and sentences missing from the report. Not
infrequently, negative contractions and the word "not" is dropped all
together. These flaws trigger concerns that the present technology could have
adverse effects on patient care. Control over quality can also be reduced when
providers choose a server-based program from a vendor Application Service Provider (ASP).
Downward adjustments in MT
pay rates for voice recognition are controversial. Understandably, a client
will seek optimum savings to offset any net costs. Yet vendors that overstate
the gains in productivity do harm to MTs paid by the line. Despite the new
editing skills required of MTs, significant reductions in compensation for
voice recognition have been reported. Reputable industry sources put the field
average for increased productivity in the range of 30%-50%; yet this is still
dependent on several other factors involved in the methodology. Metrics
supplied by vendors that can be "used" in compensation decisions
should be scientifically supported.
Another unresolved issue is
high-maintenance headers that replace simple interfaces to become the
"platform" of choice. Pay rates should reflect this lost-opportunity
cost for the MT.
Operationally, speech
recognition technology (SRT) is an interdependent, collaborative effort. It is
a mistake to treat it as compatible with the same organizational paradigm as
standard dictation, a largely
"standalone"
system. The new software supplants an MT's former
ability to realize immediate time-savings from programming tools such as macros
and other word/format expanders. Requests for client/vendor format corrections
delay those savings. If remote MTs cancel each other out with disparate style
choices, they and the recognition engine may be trapped in a seesaw battle over
control. Voice recognition managers should take care to ensure that the
impositions on MT autonomy are not so onerous as to outweigh its benefits.
Medical transcription is
still the primary mechanism for a physician to clearly communicate with other
healthcare providers who access the patient record, to advise them on the state
of the patient's health and past/current treatment, and to assure continuity of
care. More recently, following Federal and State Disability Act changes, a
written report (IME) became a requirement for documentation of a medical bill
or an application for Workers' Compensation (or continuation thereof) insurance
benefits based on requirements of Federal and State agencies.
As a profession
An individual who performs
medical transcription is known as a medical transcriptionist or an MT. An MT is also known as
a Medical Language Specialist or MLS. The equipment the
MT uses is called a medical transcriber. The individual who performs
medical transcription should always be called a "medical
transcriptionist." A medical transcriptionist is the person responsible
for converting the patient's medical records into text from recorded dictation.
The term transcriberdescribes the electronic
equipment used in performing medical transcription, e.g., a cassette player
with foot controls operated by the MT for report playback and transcription.
There have been industry discussions centered around whether or not medical
transcriptionists should be called something else; no other industry-wide term
has been adopted.
Education and training can
be obtained through certificate or diploma programs, distance learning, and/or
on-the-job training offered in some hospitals, although there are countries
currently employing transcriptionists that require 18 months to 2 years of
specialized MT training. Working in medical transcription leads to a mastery in
medical terminology and editing, MT ability to listen and type simultaneously,
utilization of playback controls on the transcriber (machine), and use of foot
pedal to play and adjust dictations - all while maintaining a steady rhythm of
execution.
While medical transcription
does not mandate registration or certification, individual MTs may seek out
registration/certification for personal or professional reasons. Obtaining a
certificate from a medical transcription training program does not entitle an
MT to use the title of Certified Medical Transcriptionist (CMT). The CMT
credential is earned by passing a certification examination conducted solely by
the Association for Healthcare Documentation Integrity (AHDI), formerly the
American Association for Medical Transcription (AAMT), as the credentialing
designation they created. AHDI also offers the credential of Registered Medical
Transcriptionist (RMT). According to AHDI, the RMT is an entry-level credential
while the CMT is an advanced level. AHDI maintains a list of approved medical
transcription schools.
There is a great degree of
internal debate about which training program best prepares a MT for industry
work.[2] Yet, whether one has
learned medical transcription from an online course, community college, high
school night course, or on-the-job training in a doctor's office or hospital, a
knowledgeable MT is highly valued. In lieu of these AHDI certification
credentials, MTs who can consistently and accurately transcribe multiple
document work-types and return reports within a reasonable turnaround-time
(TAT) are sought after. TATs set by the service provider or agreed to by the
transcriptionist should be reasonable but consistent with the need to return
the document to the patient's record in a timely manner.
While most medical
transcription agencies prefer candidates with a minimum of 1-year experience,
formal instruction is not a requirement, and there is no mandatory test. Some
hospitals require nothing more than a diploma for employment as a medical
transcriptionist. The average pay range for an in-house medical
transcriptionist in a hospital setting is $8/hr.
As of March 7, 2006, the MT
occupation became an eligible U.S. Department of Labor Apprenticeship, a 2-year
program focusing on acute care facility (hospital) work. In May 2004, a pilot
program for Vermont residents was initiated,
with 737 applicants for only 20 classroom pilot-program openings. The objective
was to train the applicants as MTs in a shorter time period. (See Vermont
HITECH for pilot program established by the Federal Government Health and Human
Services Commission).
Curricular requirements, skills and abilities
experience that is directly
related to the duties and responsibilities specified, and dependent on the
employer (working directly for a physician or in hospital facility).
§
Knowledge of medical terminology.
§
Above-average spelling, grammar, communication and memory
skills.
§
Ability to sort, check, count, and verify numbers with
accuracy.
§
Skill in the use and operation of basic office
equipment/computer; eye/hand/foot coordination.
§
Ability to follow verbal and written instructions.
§
Records maintenance skills or ability.
§
Above-average to excellent typing skills.
Basic MT knowledge, skills and abilities
§
Knowledge of basic to advanced medical terminology is
essential.
§
Knowledge of anatomy and physiology.
§
Knowledge of disease processes.
§
Knowledge of medical style and grammar.
§
Average verbal communication skills.
§
Above-average memory skills.
§
Ability to sort, check, count, and verify numbers with
accuracy.
§
Demonstrated skill in the use and operation of basic
office equipment/computer.
§
Ability to follow verbal and written instructions.
§
Records maintenance skills or ability.
§
Above-average typing skills.
§
Knowledge and experience transcribing (from training or
real report work) in the Basic Four work types: History and Physical Exam,
Consultation, Operative Report, and Discharge Summary.
§
Knowledge of and proper application of grammar.
§
Knowledge of and use of correct punctuation and
capitalization rules.
§
Demonstrated MT proficiencies in multiple report types
and multiple specialties.
Duties and responsibilities
§
Accurately transcribes the patient-identifying
information such as name and Medical Record or Social Security Number.
§
Transcribes accurately, utilizing correct punctuation,
grammar and spelling, and edits for inconsistencies.
§
Maintains/consults references for medical procedures and
terminology.
§
Keeps a transcription log.
§
In some countries, MTs may sort, copy, prepare, assemble,
and file records and charts (though in the United States (US) the filing of
charts and records are most often assigned to Medical Records Techs in
Hospitals or Secretaries in Doctor offices).
§
Distributes transcribed reports and collects dictation
tapes.
§
Follows up on physicians' missing and/or late dictation,
returns printed or electronic report in a timely fashion (in US Hospital, MT
Supervisor performs).
§
Performs quality assurance check.
§
May maintain disk and disk backup system (in US Hospital,
MT Supervisor performs).
§
May order supplies and report equipment operational
problems (In US, this task is most often done by Unit Secretaries, Office
Secretaries, or Tech Support personnel).
§
May collect, tabulate, and generate reports on
statistical data, as appropriate (in US, generally performed by MT Supervisor).
The medical transcription process
When the patient visits a
doctor, the latter spends time with the former discussing his medical problems,
including past history and/or problems. The doctor performs a physical
examination and may request various laboratory or diagnostic studies; will make
a diagnosis or differential diagnoses, then decides on a plan of treatment for
the patient, which is discussed and explained to the patient, with instructions
provided. After the patient leaves the office, the doctor uses a
voice-recording device to record the information about the patient encounter.
This information may be recorded into a hand-held cassette recorder or into a
regular telephone, dialed into a central server located in the hospital or
transcription service office, which will 'hold' the report for the
transcriptionist. This report is then accessed by a medical transcriptionist,
it clearly received as a voice file or cassette recording, who then listens to
the dictation and transcribes it into the required format for the medical
record, and of which this medical record is considered a legal document. The
next time the patient visits the doctor, the doctor will call for the medical
record or the patient's entire chart, which will contain all reports from
previous encounters. The doctor can on occasion refill the patient's
medications after seeing only the medical record, although doctors prefer to
not refill prescriptions without seeing the patient to establish if anything
has changed.
It is very important to
have a properly formatted, edited, and reviewed medical transcription document.
If a medical transcriptionist accidentally typed a wrong medication or the
wrong diagnosis, the patient could be at risk if the doctor (or his designee)
did not review the document for accuracy. Both the doctor and the medical
transcriptionist play an important role to make sure the transcribed dictation
is correct and accurate. The doctor should speak slowly and concisely,
especially when dictating medications or details of diseases and conditions,
and the medical transcriptionist must possess hearing acuity, medical
knowledge, and good reading comprehension in addition to checking references
when in doubt.
However, some doctors do
not review their transcribed reports for accuracy, and the computer attaches an
electronic signature with the disclaimer that a report is "dictated but not read". This electronic signature
is readily acceptable in a legal sense. The transcriptionist is bound to
transcribe verbatim (exactly what is said) and make no changes, but has the
option to flag any report inconsistencies. On some occasions, the doctors do
not speak clearly, or voice files are garbled. Some doctors are, unfortunately,
time-challenged and need to dictate their reports quickly (as in ER Reports).
In addition, there are many regional or national accents and
(mis)pronunciations of words the MT must contend with. It is imperative and a
large part of the job of the Transcriptionist to look up the correct spelling
of complex medical terms, medications, obvious dosage or dictation errors, and
when in doubt should "flag" a report. A "flag" on a report
requires the dictator (or his designee) to fill in a blank on a finished
report, which has been returned to him, before it is considered complete.
Transcriptionists are never, ever permitted to guess, or 'just put in anything'
in a report transcription. Furthermore, medicine is constantly changing. New
equipment, new medical devices, and new medications come on the market on a
daily basis, and the Medical Transcriptionist needs to be creative and to
tenaciously research (quickly) to find these new words. An MT needs to have
access to, or keep on memory, an up-to-date library to quickly facilitate the
insertion of a correctly spelled device,
Outsourcing of medical transcription
Due to the increasing
demand to document medical records, countries have started to outsource the
services of medical transcription. In theUnited States, the
medical transcription business is estimated to be worth US$10 to $25 billion
annually and growing 15 percent each year. The main reason for outsourcing is
stated to be the cost advantage due to cheap labor in developing countries, and
their currency rates as compared to the U.S. dollar.
There is a volatile
controversy on whether medical transcription work should be outsourced, mainly
due to three reasons:
1. The greater majority of MTs
presently work from home offices rather than in hospitals, working off-site for
"national" transcription services. It is predominantly those
nationals located in the United States who are striving to outsource work to
other-than-US-based transcriptionists. In outsourcing work to sometimes
lesser-qualified and lower-paid non-US MTs, the nationals unfortunately can
force US transcriptionists to accept lower rates, at the risk of losing
business altogether to the cheaper outsourcing providers. In addition to the
low line rates forced on US transcriptionists, US MTs are often paid as ICs (independent contractors); thus, the nationals save on
employee insurance and benefits offered, etc. Unfortunately for the state of
healthcare-related administrative costs in the United States, in outsourcing,
the nationals still charge the hospitals the same rate as they did in the past
for highly qualified US transcriptionists but subcontract the work to non-US
MTs, keeping the difference as profit.
3. The quality of the finished
transcriptions is a concern. Many outsourced transcriptionists simply do not
have the requisite basic education to do the job with reasonable accuracy, as
well as additional, occupation-specific training in medical transcription. Many
foreign MTs who can speak English are not familiar with American expressions
and/or the slang doctors often use, and can be unfamiliar with American names
and places. An MT editor, certainly, is then responsible for all work
transcribed from these countries and under these conditions. These outsourced
transcriptionists often work for a fraction of what transcriptionists are paid
in the United States, even with the US MTs daily accepting lower and lower
rates. However, some firms choose to employ American transcriptionists as they
believe the quality of work is better.
Among outsourcing
countries, the Philippines has recently attracted
increased amounts of MT outsourcing from the United States due to the fact that
English is one of the official languages used in all government transactions in
the country and the high literacy in the English language and perhaps the
capability of average Filipino to understand American idioms, colloquialism, and
slang used in medical transcription as compared to the Indians who are more
familiar with British English, since they were a former colony of theirs. This
is very concerning to the US MTs. HIPAA. governs outsourcing of MT
work. Stricter policies in compliance with HIPAA are implemented in such
companies to enable security and confidentiality of work involved in such
practices.
Transcription Process
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Clients can dictate medical transcription to us from home or the office at any time. The recorded digitally voice files are then sent to our in-house transcriptionists for transcription.
Dictation OptionsWe offer two convenient dictation options to choose from: 1. Handheld Digital Voice Recorders (Olympus, Sony etc.):This option is best suited for clients who have a computer, an Internet connection, and who need an inexpensive and portable solution for their dictation needs. Using a hand held digital recorder, clients can record dictations at any time, anywhere. Once recorded, the dictations can be sent to us by connecting the digital recorder to a computer and transferring the dictations to our server. 2. Telephonic Dictation: Eyered's phone-in toll free dictation facility can be conveniently accessed from home, office, or cell phone. Using a PIN number, an Account number, and the toll-free number to call, clients can record dictations at any time from anywhere. Once recorded, the voice files are then automatically submitted to the designated transcribers for transcription and delivery.
WorkflowFor a graphical representation of our actual workflow within our facilities, please visit out Quality Page.
Transcription Delivery OptionsDictation can be transcribed into MS Word 2000, Word Perfect or simple Text formats. Transcribed files are then encrypted and can be returned by email, secure FTP or VPN transfers.
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