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.
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.
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