Medical Transcriptionist Overview

Medical transcriptionists, sometimes referred to as healthcare documentation specialists, listen to voice recordings that physicians and other healthcare workers make and convert them into written reports. They also may review and edit medical documents created using speech recognition technology. Transcriptionists interpret medical terminology and abbreviations in preparing patients’ medical histories, discharge summaries, and other documents.

Medical transcriptionists typically do the following:

• Listen to the recorded dictation of a doctor or other healthcare worker
• Transcribe and interpret the dictation into diagnostic test results, operative reports, referral letters, and other documents
• Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and consistent in style
• Translate medical abbreviations and jargon into the appropriate long form
• Identify inconsistencies, errors, and missing information within a report that could compromise patient care
• Follow up with the healthcare provider to ensure the accuracy of the reports
• Submit health records for physicians to approve
• Follow patient confidentiality guidelines and legal documentation requirements
• Enter medical reports into electronic health records (EHR) systems
• Perform quality improvement audits

Traditionally, medical transcriptionists used audio playback equipment or software that is connected to their computer. However, technological advances have changed the way medical transcription is done. In the past, medical transcriptionists would listen to an entire dictation to produce a transcribed report. While many transcriptionists still perform these traditional transcription services, others are taking on additional roles. Today, many medical documents are prepared with the use of speech recognition technology, in which specialized software automatically prepares an initial draft of a report. The transcriptionist then reviews the draft for accuracy, identifying any errors and editing the report, when necessary. They use word-processing and other specialized software, as well as medical reference materials, as needed.

To do their work, medical transcriptionists must become familiar with medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. Their ability to understand what the healthcare worker has recorded, correctly transcribe that information, and identify any inaccuracies in the transcript is critical to reducing the chance that patients will get ineffective or even harmful treatments.

Transcriptionists may need to be familiar with EHR systems. They may create templates, help develop documentation policies, and train physicians on how to use EHR systems.

Medical transcriptionists who work in doctors’ offices may have other duties, such as answering phones and greeting patients.