MEDICAL TRANSCRIPTION COURSES IN COIMBATORE

   

MEDICAL TRANSCRIPTION COURSE

Medical transcription, also known as MT, is an allied health profession which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals into text format. An individual who performs medical transcription is known as a medical transcriptionist or an MT, or (less frequently) a medical transcriber. A medical transcriptionist is the person responsible for converting the patient's medical records into typewritten format rather than handwritten, the latter more prone to misinterpretation by other healthcare providers. The term transcriber also describes the electronic equipment used in performing medical transcription, e.g., a cassette player with foot controls operated by the MT for report playback and transcription. In the late 1990s, medical transcriptionists were also given the title of Medical Language Specialist or Health Information Management (HIM) paraprofessional. There are no "formal" educational requirements to be a medical transcriptionist. Education and training can be obtained through traditional schooling, certificate or diploma programs, distance learning, and/or on-the-job training offered in some hospitals, although there are foreign countries currently employing transcriptionists that require 18 months to 2 years of specialized MT training. Working in medical transcription leads to a mastery in medical terminology and editing, MT ability to listen and type simultaneously, utilization of playback controls on the transcriber (machine), and use of foot pedal to play and adjust dictations - all while maintaining a steady rhythm of execution. While medical transcription does not mandate registration or certification, individual MTs may seek out registration/certification for personal or professional reasons. Obtaining a certificate from a medical transcription training program does not entitle an MT to use the title of Certified Medical Transcriptionist (CMT). The CMT credential is earned by passing a certification examination conducted solely by the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), as the credentialing designation they created. AHDI also offers the credential of Registered Medical Transcriptionist (RMT). According to AHDI, the RMT is an entry-level credential while the CMT is an advanced level. In addition to their certifications, AHDI also offers training programs to aspiring transcriptionists. In lieu of these AHDI certification credentials, MTs who can consistently and accurately transcribe multiple document work-types and return reports within a reasonable turnaround-time (TAT) are sought after. TATs set by the service provider or agreed to by the transcriptionist should be reasonable but consistent with the need to return the document to the patient's record in a timely manner. Whether one has learned medical transcription from an online course, community college, high school night course, or on-the-job training in a doctor's office or hospital, a knowledgeable MT is highly reliable

Curricular requirements, skills and abilities
High school diploma or GED, plus range of 1 to 3 years' experience that is directly related to the duties and responsibilities specified, and dependent on the employer (working directly for a physician or in hospital facility).
Knowledge of medical terminology is helpful.
Average to above-average spelling, verbal communication and memory skills.
Ability to sort, check, count, and verify numbers with accuracy.
Skill in the use and operation of basic office equipment/computer; eye/hand/foot coordination.
Ability to follow verbal and written instructions.
Records maintenance skills or ability.
Good to above-average typing skills.
Basic MT knowledge, skills and abilities
Knowledge of basic to advanced medical terminology is essential.
Average to above-average verbal communication and memory skills.
Ability to sort, check, count, and verify numbers with accuracy.
Demonstrated skill in the use and operation of basic office equipment/computer.
Ability to follow verbal and written instructions.
Records maintenance skills or ability.
Average to above-average typing skills.
Knowledge and experience transcribing (from training or real report work) in the Basic Four work types.
Knowledge of and proper application of grammar.
Knowledge of and use of correct punctuation and capitalization rules.
Demonstrated MT proficiencies in multiple report types and multiple specialties.
Duties and responsibilities

• Accurately transcribes the patient-identifying information such as name and Medical Record or Social Security Number.
• Transcribes accurately, utilizing correct punctuation, grammar and spelling, and edits for inconsistencies.
• Maintains/consults references for medical procedures and terminology.
• Keeps a transcription log.
• Foreign MTs may sort, copy, prepare, assemble, and file records and charts.
• Distributes transcribed reports and collects dictation tapes.
• Follows up on physicians' missing and/or late dictation, returns printed or electronic report in a timely fashion 
• Performs quality assurance check.
• May maintain disk and disk backup system .
• May order supplies and report equipment operational problems.
• May collect, tabulate, and generate reports on statistical data, as appropriate.
• May take minutes of transcription department meetings (seldom).
• Performs miscellaneous job-related duties as assigned (seldom).

The medical transcription process
When the patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past history and/or problems. The doctor performs a physical examination and may request various laboratory or diagnostic studies; will make a diagnosis or differential diagnoses, then decides on a plan of treatment for the patient, which is discussed and explained to the patient, with instructions provided. After the patient leaves the office, the doctor uses a voice-recording device to record the 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, received as a voice file or cassette recording, 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 his 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, and 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, unfortunately, 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 his designee) to fill in a blank on a finished report, which has been returned to him, before it is considered complete. Transcriptionists are never, ever 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 hand, an up-to-date library to quickly facilitate the insertion of a correctly spelled device, procedure, or medication dictated.

Outsourcing of medical transcription
Due to the increasing demand to document medical records, other countries started to outsource the services of the medical transcriptionist. It is a volatile controversy on whether work should be outsourced, mainly due to three reasons: The greater majority of MTs presently work from home offices rather than actually IN Hospitals, working off-site for "National" Transcription services. .Some of the countries that now outsource transcription work are the United States, Britain, and Australia, with work outsourced to Philippines, India, Pakistan, and Canada. The lack of quality in the finished document is concerning. Many outsourced Transcriptionists simply do not have the requisite basic education to do the job with reasonable accuracy, much less additional, occupation-specific training in Medical Transcription. Many foreign MTs who can speak English are unfamiliar with American expressions and/or the slang doctors often use, are apparently unfamiliar with medical reference books, and are unfamiliar with American names and places. An MT Editor, certainly, is then responsible for all work transcribed from these countries and under these conditions. These outsourced transcriptionists often work for a fraction of what transcriptionists are paid in the United States, even with the US MTs daily accepting lower and lower rates.HIPAA (Health Insurance Portability and Accountability Act) governs outsourcing of MT work.AHDI (Association for Healthcare Documentation Integrity) is one of the world’s largest association for medical transcription. AHDI's mission is to lead the evolution of medical transcription, represent and advance the profession and its practitioners. AHDI has a summary of rules in medical transcription that guide companies in facilitating seamless and workable transcription processes.

The future of medical transcription
The medical transcription industry will continue to undergo metamorphosis based on many contributing factors like advancement in technology, practice workflow, regulations etc. The evolution toward the electronic patient record demonstrates that, over time, documentation habits will change either through standards and regulations or through personal preferences. Until recently, there were few standards and regulations that MTs and their employers had to meet. First, we had the Health Insurance Portability and Accountability Act (HIPAA). It wasn't long ago "experts" stated that HIPAA would not have any effect on the medical transcription industry. Either in a state of denial or ignorance of the law, many transcriptionists and companies have continued on their existing course of providing medical transcription. Many providers are concerned that the majority of the transcription industry will not be able to meet several specific requirements: namely, access controls, policies and procedures, and audits of access to the patient information. Without the knowledge or resources to comply, many in the industry are claiming to comply and signing their Business Associates Agreements without taking the security measures required. Many are uninformed, and some are choosing to remain so, believing that the world of transcription cannot possibly be expected to make these adaptations. The fact is that the employers will demand HIPAA compliance and will change employees and contractors when they don't get it. There will also be demands to enhance patient safety, increase efficiency, and reduce costs. It is mandatory for service providers and healthcare practices to migrate to a HIPAA compliant environment.

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MEDICAL TRANSCRIPTION

 

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