INTRODUCTION TO MEDICAL TRANSCRIPTION
TRANSCRIPTION: Transcription means changing of one version (voice dictation) to another (text format). Medical Transcription means, transcribing the patient's health records, dictated by the consulting Doctor, into text format.
HEALTH RECORD:
Definition of the Health Record: The health record is chronological, documented evidence of a patient’s initial data base, initial evaluation, identified problems and needs, objectives of care, prescribed treatment, and end results. Health record is to denote both illness and wellness of the patient. The health record is the property of the hospital and can’t be removed from the premises without a subpoena or a court order. The health record is maintained in the Health Information Department headed by an RRA (registered record administrator) or an ART (accredited record technician).
PURPOSE OF THE HEALTH RECORD:
1. The health record is a measurement of care being rendered in a facility. It is utilized to plan, communicate, and evaluate the quality of care being given to each patient.
2. The health record is a “proof or work done”. It contains documentation to meet federal, state, and JACHO (Joint Commission on Accreditation of Healthcare Organizations) standards and regulations as well as those for reimbursement and third party payer requirements.
3. The health record is maintained for medicolegal protection for the patient, facility, staff and physician.
4. The health record is used for research, compiling statistics, and evaluation of healthcare delivery.
ORIGIN OF THE HEALTH RECORD:
In hospitals the health record begins in the Admission Department (if the patient gets admission in the hospital), or in the Outpatient Department (if the patient gets treatment as an outpatient), or in the Emergency Department (if the patient attends for an emergency). After observation and evaluation in the Emergency Room, if necessary, the patient will be admitted.
ENTRIES IN HEALTH RECORD:
These departments have to collect patient’s identification and demographic information. The correct spelling of the patient’s legal name and date of birth are crucial elements to determine positive patient’s identification. The information is utilized to assign the health record number that is maintained for the lifetime of the patient and should be recorded on all transcribed reports.
Additional identification entries are the address, next of kin, place of birth, social security number, occupation, sex, marital status, ethnic origin, and admitting diagnosis. The final entries will be the employer, job title, address of company, insurance company, person responsible for emergency notification and payments, type of coverage, insurance identification number, and type of payment plan.
The patient’s consent will be taken for treatment and responsibilities as a patient. Throughout health care additional informed consents for surgery, procedure, invasive diagnostic tests, transfer, et cetera, will be obtained.
The patient is assured of the health care record confidentiality.
MEDICAL ENTRIES:
1. Physician’s orders for tests and investigations.
2. Nursing entries to establish a patient care plan, and set up forms for documentation of graphic information, such as vital signs (temperature, pulse, respiration, blood pressure, and weight). Patient’s intake and output, diet and hygiene records, medication records, et cetera.
3. Physician’s entries: History and physical examination, laboratory data, diagnosis, hospital course, medications and plan (while discharging the patient).
TRANSCRIBING THE HEALTH RECORD:
Physician dictates the entries made in the health record. This dictation is sent to a transcriptionist. This medical transcriptionist, specially trained for transcribing health records, by hearing the voice dictation converts into text format according to the client’s preference. To execute this transcription work the person needs training, as he/she is not familiar with this medical field.
HOW TO TRAIN THE STUDENTS FOR MEDICAL TRANSCRIPTION:
First, let us question ourselves what type of work that we do. The work is nothing but transcribing the audio dictation of patient's health records into text format. It seems to be very simple but difficult to execute. The reasons are many and among them we discuss following two important problems.
1.) The dictation of the patient's health record is related to medical field. This medical field is new and unknown to every non-medical student.
2.) Doctors dictate these heath records. So, a new problem arises when the student exposed to the voices of different doctors. These doctors are multinational origin with different accent in pronouncing the English vocabulary. The main hurdle for MTs (whose mother tongue is not English) is to understand the slang and accent of these multinational doctors.
Let us discuss now the problems in detail. Exposing the student to medical field solves the first problem. They need to understand the medical terminology (in relation to spelling, pronunciation and meaning of the medical word) and the health records.
MEDICAL TERMINOLOGY:
ANDHRASCRIBE has prepared 10,000 words, which are commonly used in medical practice, and teaches the medical terminology to the students. The student has to pronounce, spell, write and type these words with 100% accuracy. It also teaches about the medical prefixes, suffixes and combining forms with their meanings. Most of the medical terms have Latin word root. And a list of Latin words is prepared for reference. We teach human anatomy and physiology in brief.
HEALTH RECORDS:
Medical Specialties:
Students are unfamiliar and new to the contents and variety of medical dictations. The dictations are from various medical specialties, like Cardiology, Dermatology, Pulmonology, Neurology, Obstetrics & Gynecology, Urology & Nephrology, Gastroenterology, Otorhinolaryngology (E.N.T), Ophthalmology, Psychiatry, Endocrinology, Radiology, Orthopedics, Hematology, Oncology, Immunology reports etc.
All these specialties are taught to students about their basic anatomy and physiology.
Titles of various Dictations:
And there are many titles of dictations, like Chart notes, Discharge summaries, Reference letters, Office Note, Consultation report, SOAP notes, Operative surgery reports, Autopsy reports, Physical Examination reports, Labor & delivery reports,
And in addition a few more investigation reports are sent in dictations.
They are Test and Procedure reports, Treadmill stress test reports, Neuropsychological evaluation reports, Pathology reports, Radiology reports, etc.
Content of Dictations:
Dictations have some sequential procedure.
For example: A patient visits a clinic/hospital for his medical problem. No doctor gives him an injection/tablet and then asks for the complaint. This is not the correct procedure. Student has to think with his/her personal experience what will happen when he/she attends a clinic/hospital as a patient.
WHAT HAPPENS WHEN A PATIENT VISITS A CLINIC/HOSPITAL:
· The secretary of doctor first registers the patient's identification and demographic information, like name, age, sex, date of birth, address and date of examination.
· Then consulting doctor collects the history of complaint from the patient.
· After collecting necessary history from the patient then the consulting doctor starts physical examination.
· After completing physical examination, if necessary, doctor will order investigations to arrive at a diagnosis.
· A diagnosis or assessment is made.
· After the diagnosis, treatment will be given by prescribing medications (as an outpatient).
· Or hospital course starts if the patient needs admission for treatment.
· After recovery from the disease, the doctor discharges the patient with a given plan.
WHAT IS THE USE OF KNOWING THIS SEQUENTIAL ORDER:
This is the sequential procedure followed in medical practice. A detailed discussion about this procedure is necessary to make the Transcriptionist familiar with the sequence of medical dictations. MTs must be in a position to know and assume the sequential order of the headings with their content in dictation. This knowledge is useful to assume the content of the difficult part of dictation, where some times with poor audio recording. Generally, every MT leaves a blank when he/she is unable to transcribe that part in the first attempt. While proofreading the text document, they will try to fill the blank by adopting a procedure, which is discussed below.
FILL THE BLANK SPACE:
Do this exercise step-by-step as given below:
· Make a note of the specialty of the dictation.
· In which heading of the dictation the blank space left,
· Read the typed dictation, which may show some clue for assuming the word in the blank,
· Make a note whether it is a general English word or medical,
· Try to detect with which alphabet the word starts, (check for silent letter at the beginning. A brief list of those words is provided in MT Diary reference book).
· Search for probable words starting with that alphabet,
· Look for the word by category, e.g., disease, syndrome, phenomenon, sign, muscle, bone, nerve, etc.
· Apply those words in the blank then hear the dictation again and again,
· Select and type the correct word which is suitable in the blank with a meaning,
If still not able to fill the blank, then
· Close the computer for some time, relax and open it again,
· Ask a friend for opinion, or mark for proofreader,
Or
· Search for the old records of the doctor to assess his/her taste of using the words,
· If you find the correct word confidently, fill the blank,
Or
If you can’t find the word, do not enter a guess. Leave a blank.
What Does A Medical Transcriptionist Do?
Medical transcription is like nothing else you’ll ever experience. Doctors see patients in hospitals, clinics and physicians’ offices and dictate important information about the patient’s history, physical examination, diseases, procedures, laboratory tests and diagnoses. They talk in technical terms and often so quickly that you must know approximately what they are supposed to say or you won’t be able to understand it when you hear it!
New students often think that the "dictation" doctors do is like some executive dictating a letter to a secretary, in which he/she specifies every line break, every paragraph, every punctuation mark, and most of the spelling. This is absolutely NOT how doctors dictate. They expect the medical transcriptionist to do the formatting, the spelling, and to convert that dictated material from the doctor’s shorthand medical slang to formal medical language.
Doctors often say things in their dictation that they never intend to be transcribed. They say, "Oh, no, start over," "Go back and change that," and make all sorts of chitchat. They tell the transcriptionist jokes, relate cute stories, and they sing! They have conversations with people around them and often do this WHILE doing the actual dictation.
Example of something a medical transcriptionist might hear:
"The patient is a 32-year-old put him in room 2 white male who presented with a yeah, start an IV chief complaint of rats I can't find it what was this guy's problem when he got here? Never mind belly pain (rattle of x-ray film) ...okay, she can go; this is clear."
They also often begin and end by saying hello, goodbye, thank you, and have a nice holiday. They don't intend for this to be transcribed. The job of the medical transcriptionist is to figure out what is supposed to be part of the report and what is not. We are not robots who simply repeat everything we hear. We use judgement in deciding what to include and what not to include. Even if you are asked to do "verbatim" transcription, they NEVER expect you to type every noise the dictator makes. We don't transcribe noises; we transcribe and interpret meaning. We do that without changing the style of the physician’s dictation and without ever changing the medical meaning. The end result is that the report says exactly what the doctor wants it to say.
That’s what medical transcriptionists do.
In simple words, medical transcription is just “typing what the doctor/nurse says.” Basically it is a typist’s job. The treatment given for a patient at each point needs to be recorded for various processes including insurance claims in the US. The one who types these medical records is called a transcriber or a transcriptionist and the act of doing that, transcription.
In those earlier days, transcriptionists used to type with a typing machine by listening to audio tapes dictated by the doctors. Times have changed and technology too. Medical transcription has now become an IT enabled service (ITES). Now transcriptionists type with the aid of computer word processors and voice players; there by almost everything in this process confined to computers and internet.
The terminologies involved and the accent of different persons makes it a bit difficult job.
It was in the mid/latter part of the nineties that medical transcription started creeping into Asian countries, creating incredible job opportunity; thanks the advantage and proliferation of internet.
Initially, companies were working with US clients and their medical records, converting them from audio to text. Now clientele of companies have extended to UK, Australia, Canada etc.
Apart from medical transcription, there is business transcription where conferences, discussions, meetings etc., too are transcribed depending upon the requirements of various clients.
