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.

Medical transcriptionists typically need postsecondary education. Prospective medical transcriptionists must have an understanding of medical terminology, anatomy and physiology, grammar, and word-processing software.

Employers prefer to hire transcriptionists who have completed postsecondary education in medical transcription, which is offered by vocational schools, community colleges, and distance-learning programs. Medical transcription programs are typically 1-year certificate programs, although there are also associate’s degree programs.

Programs normally include coursework in anatomy, medical terminology, risk management, legal issues relating to healthcare documentation, and English grammar and punctuation. Many of these programs include supervised on-the-job experience. Some transcriptionists, especially those already familiar with medical terminology from previous experience as a nurse or medical secretary, become proficient through refresher courses and training.

Although certification is not required, some medical transcriptionists choose to become certified. The Association for Healthcare Documentation Integrity offers the Registered Healthcare Documentation Specialist (RHDS) and the Certified Healthcare Documentation Specialist (CHDS) certifications. Both certifications require passing an exam and periodic retesting or continuing education.

The RHDS certification, formerly known as the Registered Medical Transcriptionist (RMT), is for recent graduates with less than 2 years of experience and who work in a single specialty environment, such as a clinic or a doctor’s office.

The CHDS certification, formerly known as the Certified Medical Transcriptionist (CMT), is for transcriptionists who have at least 2 years of experience and those who handle dictation in several medical specialties.

Computer skills. Medical transcriptionists must be comfortable using computers and word-processing software, because those tools are an essential part of their jobs. Transcriptionists also may need to know how to operate electronic health records (EHR) systems.

Critical-thinking skills. Transcriptionists must be able to assess medical reports and spot any inaccuracies and inconsistencies in finished drafts. They must also be able to think critically when doing research to find the information that they need and to ensure that sources are both accurate and reliable.

Listening skills. Transcriptionists must listen carefully to dictation from physicians. They must be able to hear and interpret the intended meaning of the medical report.

Time-management skills. Because dictation must be done quickly, medical transcriptionists must be comfortable working under short deadlines.

Writing skills. Medical transcriptionists need a good understanding of the English language and grammar.