Medical transcriptionists interpret dictated information from the doctor or other healthcare professionals and convert it into documents. They create, format and edit medical records for patients based on the provided data and take care to apply punctuation and grammar rules.
Medical transcriptionists typically do the following duties:
- Listen to the recorded dictation of a physician or other healthcare worker
- Interpret and transcribe the dictation for medical reports, such as patient histories, discharge summaries, and physical examinations
- Review and edit drafts prepared by speech recognition software, making sure that the transcription is accurate, complete, and consistent in style
- Translate medical abbreviations and jargon into the appropriate long form
- Identify inconsistencies, errors, and missing information in a report that could compromise patient care
- Submit reports to physicians and other healthcare providers for review and approval
- Follow patient confidentiality guidelines and legal documentation requirements
- Enter medical reports into electronic health records (EHR) systems.
Medical transcriptionists use a variety of equipment to produce reports. The most common is speech recognition technology, which involves specialized software that 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, as necessary. A less common technology requires these workers to use audio-playback equipment for listening to and transcribing dictation. Transcriptionists also use word-processing and other software to prepare the transcripts, as well as medical reference materials when needed.
Medical transcriptionists must be familiar with medical terminology, anatomy, and physiology. Additionally, they must have knowledge of English grammar in order to ensure that their transcriptions are correct. Transcriptionists’ ability to understand the healthcare worker’s recording, to correctly transcribe that information, and to identify inaccuracies in the transcript is critical to preventing ineffective or even harmful treatment.
The following job titles also refer to medical transcriptionist:
clinical transcription typist
medical transcription suite typist
medical transcriptionist and proof reader
medical secretary-audio typist
clinical transcription suite typist
Medical transcriptionists may work from home, receiving dictation and submitting drafts electronically. Their work may be stressful because they need to ensure that reports are accurate and completed within a quick turnaround time.
Most medical transcriptionists are full time, but part-time work is common. Medical transcriptionists who work from home may work outside typical business hours and may have flexibility in determining their schedules.
A medical transcriptionist usually has an associate degree from a community college or a similar degree from a vocational school. Often a high school degree and a certificate are enough, but an advanced degree makes the medical transcriptionist more employable. Transcription education includes how to use transcription software, keyboarding, transcription, editing and proofreading and information management. Classes in medical terminology, anatomy and physiology help medical transcriptionists understand their work as medical employees.
Being a medical transcriptionist requires two to three years of education. The role of a medical transcriptionist requires a person to have experience with computer systems, transcription software and management of health care databases. The more senior medical transcriptionist roles require that someone has worked consistently five or more years as a medical transcriptionist. Some medical transcriptionist positions may require management or mentoring experience if the person focuses their work as a medical transcriptionist project manager or lead transcriptionist.
ISCO skill level
ISCO skill level is defined as a function of the complexity and range of tasks and duties to be performed in an occupation. It is measured on a scale from 1 to 4, with 1 the lowest level and 4 the highest, by considering:
- the nature of the work performed in an occupation in relation to the characteristic tasks and duties
- the level of formal education required for competent performance of the tasks and duties involved and
- the amount of informal on-the-job training and/or previous experience in a related occupation required for competent performance of these tasks and duties.
Medical transcriptionist is a Skill level 3 occupation.
Medical transcriptionist career path
These occupations, although different, require a lot of knowledge and skills similar to medical transcriptionist.
Long term prospects
These occupations require some skills and knowledge of medical transcriptionist. They also require other skills and knowledge, but at a higher ISCO skill level, meaning these occupations are accessible from a position of medical transcriptionist with a significant experience and/or extensive training.
Essential knowledge and skills
This knowledge should be acquired through learning to fulfill the role of medical transcriptionist.
- Medical terminology: The meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.
- Database: The classification of databases, that includes their purpose, characteristics, terminology, models and use such as XML databases, document-oriented databases and full text databases.
- Health records management: The procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of records.
- Grammar: The set of structural rules governing the composition of clauses, phrases, and words in any given natural language.
Essential skills and competences
These skills are necessary for the role of medical transcriptionist.
- Archive healthcare users’ records: Properly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.
- Edit dictated medical texts: Revise and edit dictated texts used for medical records purposes.
- Maintain healthcare user data confidentiality: Comply with and maintain the confidentiality of healthcare users` illness and treatment information.
- Use electronic health records management system: Use specific software for the management of health care records, following appropriate codes of practice.
- Transcribe medical data: Listen to the recordings of the healthcare professional, write the information down and format it into files.
- Apply grammar and spelling rules: Apply the rules of spelling and grammar and ensure consistency throughout texts.
- Comply with legislation related to health care: Comply with the regional and national legislation that is relevant to one`s work and apply it in practice.
- Follow given instructions: Follow instructions to achieve goals and meet deadlines.
- Apply organisational techniques: Employ a set of organisational techniques and procedures which facilitate the achievement of the goals set. Use these resources efficiently and sustainably, and show flexibility when required.
- Manage digital archives: Create and maintain computer archives and databases, incorporating latest developments in electronic information storage technology.
Optional knowledge and skills
This knowledge is sometimes, but not always, required for the role of medical transcriptionist. However, mastering this knowledge allows you to have more opportunities for career development.
- Administrative tasks in a medical environment: The medical administrative tasks such as registration of patients, appointment systems, record keeping of patients information and repeated prescribing.
- Professional documentation in health care: The written standards applied in the health care professional environments for documentation purposes of one`s activity.
- Health care system: The structure and function of health care services.
- Human anatomy: The dynamic relationship of human structure and function and the muscosceletal, cardiovascular, respiratory, digestive, endocrine, urinary, reproductive, integumentary and nervous systems; normal and altered anatomy and physiology throughout the human lifespan.
- Medical informatics: The processes and tools used for the analysis and dissemination of medical data through computerized systems.
Optional skills and competences
These skills and competences are sometimes, but not always, required for the role of medical transcriptionist. However, mastering these skills and competences allows you to have more opportunities for career development.
- Display medical problems: Emphasize significant medical issues in a way that the attention of any healthcare professional using the record is directed on them.
- Handle paperwork: Handle work-related paperwork ensuring that all relevant requirements are met.
- Collect healthcare user’s general data: Collect qualitative and quantitative data related to the healthcare user’s anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests performed by the practitioner.
- Use shorthand: Apply shorthand as a method to capture spoken words into written form. Use shorthands in written texts to reflect acronyms and relevant information required to be expressed in such fashion.
- Identify patients’ medical records: Locate, retrieve and present medical records, as requested by authorized medical personnel.
- Perform backups: Implement backup procedures to backup data and systems to ensure permanent and reliable system operation. Execute data backups in order to secure information by copying and archiving to ensure integrity during system integration and after data loss occurrence.
- Review patient’s medical data: Assess and review relevant medical data of patients such as X-rays, medical history and laboratory reports.
- Transfer medical information: Extract information from a patient’s notes and enter them in a computer programme.
- Work in multidisciplinary health teams: Participate in the delivery of multidisciplinary health care, and understand the rules and competences of other healthcare related professions.
- Perform clinical coding procedures: Match and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.
- Process data: Enter information into a data storage and data retrieval system via processes such as scanning, manual keying or electronic data transfer in order to process large amounts of data.
- Participate in medical records’ auditing activities: Assist and help with any requests arisen during audits related to the archiving, filling and processing of medical records.
ISCO group and title
3344 – Medical secretaries
- Medical transcriptionist – ESCO
- Medical Transcriptionists : Occupational Outlook Handbook – U.S. Bureau of Labor Statistics
- Medical Transcriptionist Job Description – Indeed.com
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