MEDICAL TRANSCRIPTION COURSE IN ERNAKULAM

Medical transcription (MT) is the manual processing of voice reports dictated by physicians and other healthcare professionals into text format.

The MT team of a hospital typically receives the voice files with dictation of medical documents from healthcare providers. The voice files are then converted into text.

The transcribed medical reports are usually created in digital format and submitted to the hospital's Electronic Health Record (EHR) or Electronic Medical Record (EMR) system.

Today, the medical field relies on speech recognition software and medical transcription software (MTS) for transcribing.

 

Medical records document all aspects of a person's medical care, including their symptoms, health history, the results of their healthcare providers’ exams, their diagnostic tests, as well as their treatment plan. They are vital for continuity of care and communication among healthcare providers.

Errors in medical records can affect insurance coverage or even lead to mistakes in treatment and care. Caregivers have a legal obligation to maintain accurate and up-to-date records on all patients. 

Medical transcriptionists work with healthcare providers to make sure that each visit is documented so that there is a complete record of the diagnosis and treatment plan as well as any follow-up care that may be needed.

Medical transcriptionists listen to providers' dictated notes and translate them into a clear, organized record of the visit. They ensure that all aspects of a person's history, diagnoses, and treatment are recorded. Then they use the facility's documentation system to file the medical records to be accessed at the next visit or sent to another facility if necessary. 

Education and Training

Most medical transcriptionists complete a certificate program that includes courses in medical terminology, anatomy, physiology, medical specialties, diagnostic studies, and pharmacology.

Some complete an associate's degree program. Medical transcriptionists are sometimes called medical language specialists, and they need to have an excellent command of grammar and punctuation.

They also have to be able to understand complicated medical terminology as well as medical and surgical procedures. In addition, they need to have good auditory processing skills and be able to understand accents. 

The Association for Healthcare Documentation Integrity is the professional organization for medical transcriptionists. Medical transcriptionists are eligible for one of two certifications, depending on experience.

New transcriptionists, once they have graduated from a medical transcription program, can sit for the exam to become a Registered Healthcare Documentation Specialist (RHDS). The exam is open to transcriptionists with less than two years of experience or transcriptionists who work in only one specialty. 

Once they have the RHDS certification, medical transcriptionists are eligible to become a Certified Healthcare Documentation Specialist (CHDS). To obtain their CHDS certification, transcriptionists must have at least two years of experience in an acute-care or multi-specialty clinic setting.  

They also have to have obtained their RHDS certification. To keep their certification, RHDS transcriptionists must complete 20 hours of continuing education every three years or retake the exam. To keep the CHDS certification, transcriptionists must complete 30 hours of continuing education every three years. 

The medical transcription process

 

When the patient visits a doctor, the latter spends time with the former discussing their medical problems and performing diagnostic services. After the patient leaves the office, the doctor uses a voice-recording device to record 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, 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 their 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. 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 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 their designee) to fill in a blank on a finished report, which has been returned to him, before it is considered complete. Transcriptionists are never 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.