What is Medical Transcription?

27 October 2021
GoTranscript Blog What is Medical Transcription?

Medical transcription has been around for a long time. This service is believed to have emerged in 1960 with the introduction of electronic health record systems. Before medical transcription, doctors had to transcribe by hand the health condition of patients. They also had to note down other visits from the patient.

The transcription process often took a lot of time and delayed the treatment of the patient. Hence, the idea of hiring or outsourcing medical transcription services came into being. But what is medical transcription? How does this service work? This article will detail everything you need to know about medical transcription. 

Understanding Medical Transcription

Medical transcription is a process by which medical reports dictated by physicians and other healthcare providers are converted from voice into text format. The voice reports contain clinical summaries, lab results, surgery notes, and other medical procedures. The purpose of medical transcription is to obtain a written record of a patient’s medical history. The transcribed files are either printed and stored as paperwork or preserved in electronic format. 

The Process of Medical Transcription

How is medical transcription done? Well, the process begins with a patient visiting the doctor. Once the patient leaves, the doctor records the patient’s medical information using a voice-recording device. They may use a hand-held digital recorder or a telephone connecting to the hospital’s or transcription agency’s central server. The doctor can also record other medical procedures such as surgery notes, diagnostic imaging studies, chart reviews, and discharge information.

The voice reports are then sent to a medical transcriptionist for conversion into text format. The medical practitioner may share them via a secure HIPAA compliant app or through an encrypted email.

The medical transcriptionist listens to the voice dictations and transcribes them to text. Accuracy is necessary when transcribing medical records because any mistakes may lead to a wrong diagnosis or treatment. Both the healthcare provider and medical transcriptionist play a part in ensuring the accuracy of patients’ information. Physicians are often encouraged to speak slowly and clearly when dictating the voice notes. They should also review the transcribed document once complete. 

At times, the doctor may be too busy to review the transcribed documents. In this case, the hospital can attach an e-signature with a disclaimer such as “dictated but not reviewed.”

There are also instances when the doctor is time-poor and has to record the reports quickly, for example, when dictating emergency room summaries. Such voice notes may be challenging for the medical transcriptionist to transcribe. The transcriber should look up the medical terms, medications, and any other dictation errors when transcribing. When in doubt, the medical transcriptionist can flag the report once he finishes. A flagged file goes back to the doctor or dictator for review and editing before being marked as complete.

Once the medical transcriptionist finishes transcribing, the written record is sent to the hospital for storage and retrieval whenever needed. The transcribed notes are considered a legal document.

Some doctors prefer to do the transcription work themselves as opposed to outsourcing. They usually take voice notes in the day then transcribe them at the end of their workday. Most, however, prefer to work with a medical transcriptionist hired by the hospital or outsource the service to a transcription agency. 

The Importance of Medical Transcription

Medical transcription is considered a part of the healthcare industry. Why is this service important? Is medical transcription worth it? Let’s have a look at the benefits that medical transcription brings to the health industry. 

1. Increases Job Satisfaction for Medical Practitioners

Doctors, nurses, and other healthcare practitioners are often busy attending to patients. They rarely have any spare time to transcribe their voice notes, let alone go through paperwork. Many opt to outsource the transcription service to medical transcribers.

Medical transcription services reduce the workload that comes with doctors and nurses transcribing their own voice notes. By outsourcing the service, medical practitioners experience less burnout, and thus they enjoy their work more. Most medical transcription providers integrate their systems with the hospital’s electronic health record system (EHRs). The integration enables transcribers to send complete files directly to the EHR system. The only task that medical practitioners have to do is retrieve the document for review and during the patient’s visit. 

2. Enables Healthcare Providers to Focus on Patients

The transcription process can be pretty lengthy, depending on the amount of dictated content and speed of the medical transcriber. With the workload reduced, physicians and healthcare providers can focus on caring for patients. Thanks to medical transcription services, physicians can use this time to attend to more patients, which leads to more revenue for the hospital and higher patient satisfaction. 

3. Increases Efficiency

Outsourcing medical transcription services is beneficial to both patients and physicians. It reduces the turnaround time between patient visits. Patients don’t have to wait for the doctor to write down or to transcribe the voice recordings. The doctor just needs to listen to the patient then record a summary after the session. 

4. Reduces Costs

For outsourced medical transcription services, the medical practitioner only pays for a single transcribed file. They don’t have to pay a full salary with benefits unless they hire a full-time medical transcriber. This significantly reduces costs, and it goes hand in hand with the number of patients that visit the doctor. 

5. Enables Quick Review of Patient’s History

Most physicians review a patient’s history before diagnosing or giving a prescription. With a transcribed record, the physician can quickly glance over the patient’s medical information. It’s easier for the doctor to go through a written file than listen to an entire voice note. 

How is Medical Transcription Different From General Transcription?

General transcription covers all other fields, while medical transcription is strictly focused on the healthcare industry. The difference between the two is that medical transcription requires specialized MT training. The training focuses on grammar, accuracy, types of medical records, and confidentiality issues. Transcribers should undergo school training on medical anatomy and terminology before seeking work as medical transcriptionists. 

Specialized MT training is necessary because the transcriptionist must be familiar with the medical terminology. A transcriber who doesn’t have an adequate medical background may have difficulty understanding the medical vocabulary. Inaccurate medical transcription can cause severe problems and even put the patient’s life at risk. 

Medical Transcription Versus Voice to Text Software

Automation has taken up the task of many transcription processes. Businesses and companies can now rely on voice-to-text software to convert voice notes to text format. Automated transcription is, however, not recommended in the healthcare industry.

Voice to text software can transcribe basic dictations. This software may, however, misunderstand terms in the medical language and transcribe them inadequately. The inaccuracies may put the patient at risk of misdiagnosis. For voice-to-text software to work, there needs to be a medical transcriptionist who can review and edit the transcribed files.  

The Role of Medical Transcriptionists

Aside from converting voice reports into written records, other tasks of a medical transcriptionist may include:  

  • Keeping the patient’s information confidential 

Medical transcribers should maintain the confidentiality of the patient’s information as required by HIPAA (Health Insurance Portability and Accountability Act of 1996). They should work in a private area and use a secure computer to transcribe. The transcriptionists should also not leave patients’ information open on the computer when away.  

  • Editing and proofread transcribed reports 

Medical transcriptionists should edit and proofread the voice reports in the required formats for ease of review by the doctor. Again, accurate medical transcription is crucial because errors can cause serious problems.  

  • Staying informed on changes in the healthcare industry 

The medical industry keeps evolving. New findings, equipment, and treatment methods are constantly introduced in the field. Medical transcribers are encouraged to be up to date with these developments to ensure their work is accurate. They should always do research when in doubt. 

In Closing

Medical transcription refers to the conversion of voice dictations of a patient’s medical information into text format. The purpose of medical transcription is to provide a written record that’s can easily be stored as paperwork or electronically. Most medical practitioners opt to hire or outsource medical transcription services to reduce workload and focus on the patients.

Medical transcription is different from general transcription in that it requires special MT training. The transcriber should undergo school training on medical anatomy and terminology, grammar, confidentiality issues, and more. The roles of a medical transcriber include converting medical voice notes to text, editing transcribed reports, and keeping patients’ information confidential.