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Medical Transcription will be performed by MTs who will be employees in a hospital or the persons who work from home for the hospital. The word transcript is most generally used to refer document (electronic or physical hard copy). This report is called as a medical record. A MT needs to type correct spelling of all terms that are being dictated by the physicians. All transcription reports must meet the terms with policies and confidentiality.
The process:
When the patient visits physicians, the physicians spare time with the patient analyzing his health problems which includes past history. The doctor does his physical examination and advice different laboratory examinations. When patient goes out of the hospital, the physician records the information about the patient via digital voice recorder device. This information is recorded into a cassette recorder. This recording is now accessed by a medical transcriptionist.
Knowledge and skills needed to be an MT Knowledge of medical terminology Medical Style of writing Good verbal communication Capability to sort,count, and cross the numbers Must be able to follow the written instructions Maintenance of records
Responsibilities of an MT
The transcriber needs totranscribes accurately the patients information likename or SSN (Social Security Number. ) Should transcribe with correct punctuation, spelling, grammar Maintains references for medical course and terminology Maintain a transcription sheet log Quality check
MEDICAL TRANSCRIPTION: PROVEN ACCELERATOR OF ELECTRONIC HEALTH RECORD (EHR) ADOPTION Quality and Security Standards Lead to Greater Document Compliance and Improved EHR Adoption.
Ensure the Accuracy of Data Entered into Electronic Systems: One of the primary functions that medical transcriptionists serve is that of a second set of eyes and ears to ensure the accuracy of clinical documentation.
Creating Document Standards to Improve Patient Care: Medical transcriptionists serve on the front line of risk management by creating accurate, reliable, and complete transcribed documents that help prevent medical errors, improve patient safety, and facilitate the coding and billing process for insurance programs.
A Skilled and Knowledgeable Workforce That Embraces Emerging Technologies: A Growing Industry and Profession That Boost Job Creation: New job creation is an essential component of the HITECH Act. The Medical Transcription workforce will be instrumental in assisting with the transition to EHRs and play a vital function in ensuring documentation integrity within the fully interoperable electronic health environment of the future.