Medical transcriptionists typically do the following:
- Listen to the recorded dictation of a doctor or other healthcare worker
- Interpret and transcribe the dictation into patient history, exam notes, operative reports, referral letters, discharge summaries, and other documents
- Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and consistent in style
- Translate medical abbreviations and jargon into the appropriate long form
- Identify inconsistencies, errors, and missing information within a report that could compromise patient care
- Follow up with the healthcare provider to ensure that reports are accurate
- Submit health records for physicians to approve
- Follow patient confidentiality guidelines and legal documentation requirements
- Enter medical reports into electronic health records (EHR) systems
- Perform quality improvement audits
Traditionally, medical transcriptionists used audio playback equipment to listen to an entire dictation in order to produce a transcribed report, and some transcription is still done this way. It has become more common for medical documents to be prepared using speech recognition technology, in which specialized software automatically prepares an initial draft of a report. The transcriptionist then listens to the voice file and reviews the draft for accuracy, identifying any errors and editing the report, when necessary. Transcriptionists use word-processing and other specialized software to prepare the transcripts, as well as medical reference materials when needed.
Medical transcriptionists must be familiar with medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. Their ability to understand what the healthcare worker has recorded, correctly transcribe that information, and identify any inaccuracies in the transcript is critical to reducing the chance that patients will get ineffective or even harmful treatments. Medical transcriptionists also may need to be familiar with EHR systems.
Medical transcriptionists who work in doctors’ offices may have other duties, such as answering phones and greeting patients.
- Time Pressure (98%)
- Consequence of Error (31%)
Employers prefer to hire transcriptionists who have completed postsecondary education in medical transcription, which is offered by vocational schools, community colleges, and distance-learning programs. Medical transcription programs are typically 1-year certificate programs, although there are also associate’s degree programs.
Programs normally include coursework in anatomy, medical terminology, risk management, legal issues relating to healthcare documentation, and English grammar and punctuation. Many of these programs include supervised on-the-job experience. Some transcriptionists, especially those already familiar with medical terminology from previous experience as a nursing assistant or medical secretary, become proficient through refresher courses and training.
Although certification is not required, some medical transcriptionists choose to become certified. The Association for Healthcare Documentation Integrity offers the Registered Healthcare Documentation Specialist (RHDS) and the Certified Healthcare Documentation Specialist (CHDS) certifications. Both certifications require passing an exam and periodic retesting or continuing education.
The RHDS certification, formerly known as the Registered Medical Transcriptionist (RMT), is for recent graduates with less than 2 years of experience and who work in a single specialty environment, such as a clinic or a doctor’s office.
The CHDS certification, formerly known as the Certified Medical Transcriptionist (CMT), is for transcriptionists who hold the RHDS designation. In addition, CHDS candidates must have at least 2 years of acute care experience, including experience handling dictation in various medical specialties.
To maintain certification, medical transcriptionists must complete continuing education requirements every 3 years.
- In-state comparisons: the ratio of median (middle) salaries for medical transcriptionists compared to the median salary for all people working in each state, or
- Median salary: the unaltered median salaries for medical transcriptionists.
