What Does Transcription Involve?

While there is a perception that a transcriptionist is simply a very fast typist, there is much more to the profession. Here are some examples of the skills and qualities that every successful transcriptionist must possess in order to deliver quality work and build a steady clientele.

A transcriptionist requires the skill of literacy. Because there is the opportunity for just about any word in a given language to be used during the course of a meeting or session that will require transcription, the transcriptionist must have the ability to transcribe what is heard accurately. This includes understanding colloquialisms that may be employed by various speakers, being able to use punctuation in such a way that the inflection of the speakers are captured as much as possible, and being able to record the dialogue exactly as it occurred. A well-rounded education in the art of language is an essential for any good transcriptionist.

Above and beyond basic language skills, the need to deal easily with technical terminology or simple shoptalk is very handy in many transcription jobs. For example, medical transcriptionists need to not only posses a strong medical vocabulary, but also be proficient in the abbreviations that are commonly used with the medical field. This same qualification or skill is necessary for court transcriptionists as well. Understanding the vocabulary well enough to accurately capture the flow of discussion in a document is a valuable asset for any transcriptionist.

Strong typing skills is a must for any transcriptionist. In some cases, the job has to be accomplished in a real time setting. In effect, the transcriptionist is taking dictation, without the ability to employ the old-fashioned shorthand method. Even in cases where the transcriptionist is working off an audio recording of a meeting or event, a quick delivery of the finished transcript may be very important to the client. Circumstances often dictate that a finished transcript be made available to the customer within a day or less. Fast and accurate typing skills go a long way to meeting those sorts of deadlines.

Lastly, a transcriptionist also may need to employ some research skills to the task. No matter how well versed the transcriptionist may be in a given field, chances are that he or she will have to look up a few terms or phrases that are used within a meeting or session. This research often helps the transcriptionist put the remarks into context, which aids in using appropriate punctuation. The research can also server to verify the spelling of any words that the transcriptionist may be unsure about.

The transcriptionist is a working professional who makes good use of language and language arts, research, and an affinity for understanding the meaning and intent behind the words used in a conversation. Along with these qualities, the transcriptionist also must possess strong skills at the computer keyboard. With an eye toward accuracy and a commitment to deliver a quality transcript to each customer, a transcriptionist employs a number of talents and skills to get the job done.

What is a Procedure Note?

A procedure note is a documentation of a medical procedure which is added to a patient's chart after the procedure has been completed. Procedure notes are important because they clearly indicate which procedures have been performed on a patient, when they were performed, and what the results of these procedures were. In addition, they protect hospitals and doctors from legal repercussions by clearly and concisely recording relevant data about procedures. In some cases, procedure note templates may be used to ensure uniformity.

Several pieces of information are contained in a procedure note. The name of the doctor performing the procedure and anyone else present is always included, along with detailed information about the procedure. Rather than just stating that an intravenous catheter was placed, for example, the note will say where, when, why, and how. The procedure note also includes information about anesthetics used during the procedure, and it also usually includes a note that sterile materials and protocol were utilized. Finally, a procedure note also includes a section stating that informed consent was obtained from the patient, unless the procedure was performed during a life threatening emergency.

Along with the other information in a patient's chart, procedure notes help to form a complete picture of how the patient is doing, medically. Any medical professional should be able to pick up the chart and know everything about the patient's case, from the drugs that the patient is on to everything that has been done to identify the patient's condition and treat it. Procedure notes can also be useful, because doctors will note findings and complications, alerting other medical personnel to issues which should be addressed.

The format for procedure notes is fairly standard, and it is included in the training for most medical careers. Schools which specialize in medical education want to make sure that their graduates are capable of offering quality health care and that they can document their work clearly and in a format which can stand up in court, if necessary. Although the primary focus of a procedure note is improving overall patient care, the legal protections are usually considered when medical personnel write out such notes, just to be on the safe side.

For patients, procedure notes may seem rather confusing, because they often use complex medical terminology or abbreviations. Patients do have a right to look at their medical charts, and if they are curious about anything in their charts, they can consult a doctor or medical professional for a clear explanation of any confusing information. In most countries, patients may also petition to correct inaccuracies in their charts, including inaccuracies in procedure notes.

What Does a Medical Transcriptionist Do?

A medical transcriptionist is a skilled typist, excellent at interpreting what they read or hear, and a good grammarian. They also have to have strong familiarity with medical language and terms. Further, medical transcriptionists must be able to take what they hear and edit it, transform it, or make it logical without changing relevant details or medical information.

Medical transcriptionists may work for doctors' offices, insurance companies, individual doctors, or for hospitals. Their primary job is to transcribe dictated material into clear and understandable text, generally for the purpose of charting information on patients. In order to do this, the medical transcriptionist must be able to interpret what he or she hears or reads, since not all doctors or medical workers create clear transcriptions. It’s not uncommon for medical workers to have conversations in the midst of a transcription, give directions to ignore parts of a transcription, or to leave out some relevant details that will make charting on a patient complete. When this occurs, a medical transcriptionist may have to chat with doctors regarding what they meant, but more often, they have to figure out what medical workers meant with minimal contact with the person who dictated the original material

Much of the recording that the medical transcriptionist interprets is based on either recorded tape or Dictaphone machines. This means that the medical transcriptionist must be able to understand basic dictation and short hand. More recently, the trend in dictation has been to use voice-operated software, but this doesn’t leave the medical transcriptionist without a job. Instead, material dictated to a computer has to be read, edited, interpreted, correctly punctuated, and carefully rewritten so that material is clear for anyone else reading it. Voice recognition software does not currently have the ability to correctly interpret information, and will naturally transcribe everything that is said. Medical transcriptionists may be saved a little typing when interpreting such programs, but they still must find a way to most clearly state the doctor’s intent while removing all irrelevant material.

The key to being an effective medical transcriptionist lies in the worker’s ability to decide what is relevant. This means that not only terms must be recognizable, but they must also be understood. A transcriptionist may not be able to decide what’s important without a basic knowledge of what medical terms mean. There are many training courses for the transcriptionist that focus on understanding medical terms and phrases, as well as learning common slang for these phrases, which help the transcriptionist do his/her work correctly and effectively.

How to begin Medical Transcription Career?

Medical transcriptionists write down dictated information from doctors. They then write reports based on dictation. Even if one is excellent at shorthand, one usually requires training to work in medical transcription. Some on the job learning can be offered, but physicians tend to employ only those fully trained in medical transcription.

To be successful in medical transcription, one must have excellent typing skills. The most important training in medical transcription is education in medical terms. You will need both quick typing and medical term knowledge to quickly produce reports.

Most physicians will expect completion of a certain number of reports per day. Honing listening skills is important to increase speed. Not all medical transcription uses short hand. Many are required to know shorthand, especially if they take oral reports directly from a physician.

Some junior colleges and local trade schools offer classes in medical transcription. Most often, training is completed through online or correspondence schools. Doctors tend to accept any certification of completion from an accredited school. The proof is in one's skills, however, so researching online or correspondence schools should be done carefully.

Many study medical transcription to work from home. Often those beginning a career in medical transcription have a better chance of employment if they work in a doctor’s office or hospital. Usually after a year or two of work, the medical transcriptionist can then work from home, either with the same employer, or by starting one’s own home business.

A medical transcriptionist working from home may be paid a little more in salary, but may not have access to medical benefits. However, if employment continues with a doctor or hospital, access to benefits may still be available. Small businesses can also apply for insurance through small business co-ops to help to reduce costs.

Those working in medical transcription are now in direct competition with experts in foreign countries. Using freelancers allows doctors to pay much less than minimum wage to foreign employees. Estimates suggest that the median salary for experts in medical transcription has dropped about 10% in the last few years. This may continue to drop as doctors decide to hire medical transcription experts from a foreign country to reduce health care costs.