Every detail of a patient’s medical care is recorded in their medical records, from their symptoms and medical history to the outcomes of any diagnostic tests and the prescribed course of treatment. Care coordination and provider-to-provider communication rely heavily on them. As such, medical record errors may have serious consequences, including denied insurance claims and substandard care. Hence, health care providers are required by law to keep complete and current medical records on their patients. And to record each patient’s diagnosis, treatment, and progress, a medical transcriptionist collaborates with doctors to accurately record each visit.
Transcriptionists in the medical field take dictation from doctors and hospitals and turn it into a legible report of the patient’s visit. They ensure that a patient’s medical record is kept in one place, including past illnesses, current conditions, and treatments. The medical data are then filed away using the institution’s documentation system and may be retrieved for use at a later visit or transferred to another facility if required.
Doctors, nurse practitioners, and other medical professionals often dictate personal notes regarding patient visits. Transcribers then transcribe these notes into a complete account of the visit.
Most fields of medicine have varied needs; thus, each speciality has its unique form. From time to time, they get files that are straight-up speech-to-text translations. After that, they edit and format the notes into a final draft.
Such a specialist uses their in-depth understanding of medical language and analytical prowess to reduce the number of typos introduced into the final transcript. An example of this would be a patient who is recorded as taking a drug to which they are allergic; if they encounter this discrepancy, they will stop and ask for clarification.
Certification often necessitates the completion of coursework in areas such as medical vocabulary, anatomy, physiology, medical specialities, diagnostic research, and pharmacology.
So, some pursue and get an associate’s degree, as a firm grasp of syntax and punctuation is essential for a career as a medical transcriptionist, often known as a medical language expert. And as an added need, they should have a solid understanding of medical and surgical jargon and practice’s intricacies. They should also be able to absorb auditory information quickly and correctly and comprehend speakers with different accents.
After completing a medical transcribing programme, aspiring transcriptionists are eligible to take the RHDS certification test (RHDS). Individuals with experience of fewer than two years in the field, or those who have only worked in one transcribing speciality, are eligible to take the test.
Medical typists may advance their careers to Certified Healthcare Documentation Specialist status after earning the RHDS credential (CHDS). Transcribers seeking the CHDS credential are expected to have worked in either an emergency room or a multi-speciality clinic for at least two years.
Additionally, they need to be RHDS-certified, and transcriptionists who use the RHDS standard must repeat the certification test every three years or complete 20 hours of ongoing education. Also, transcribers must participate in 30 hours of continuing education every three years to maintain their CHDS certification.
Reasons to See a Medical Transcription Professional
Transcriptionists in the medical field work closely behind the scenes with your doctor to ensure that your medical records are accurate and may be shared with other doctors if necessary. You will most likely never meet them in the ordinary course of therapy.
However, you may inspect their work if you ask for a copy of your medical records. Nevertheless, it’s wise to double-check your health records for accuracy.
Generally speaking, you have the right under HIPAA to see and copy your health records. Your electronic medical record (EMR) may be accessed via the websites of many healthcare providers. And even if they don’t, you have the right to see your files, keep them private, and have any inaccuracies corrected if you think they exist. Meanwhile, if you are a medical professional seeking a transcriptionist for your facility, you may find such service providers easily online.