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Medical Transcription | A minefield

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Medical Transcription

As a medical transcription typing service provider, I have been asked to write a short piece on what medical transcription is today, what it has meant to me, and what medical transcription typing service providers need.
In its purest form medical transcription involves turning audio dictation (sometimes supplemented with written notes) and turning it into a magnificent typed transcript, accurate and clear.

Medical transcription requires the highest standards of accuracy in medicine, in English, in grammar and in syntax. The slightest mistake in a patients records can have life threatening implications.

Pursuit of excellence and embracing change are the two most needed characteristics for medical transcription typing service providers today. We must be medical language specialists, medical word editors, team players, technologists, and diction experts for doctors dictating notes for whom English is perhaps not their first language.

I’ll try to give you some ideas from a multifaceted approach, and perhaps enclose a little humor, as well, because I believe that taking a lighthearted but sure approach and keeping perspective is good for the soul.

There are many associations and organisations offering wonderful resources and ideas relating specifically to medical transcription. By way of example, the Journal for the American Association for Medical Transcription (JAAMT) has hundreds of wonderful articles on what exactly transcription is, where it is headed, the impact of outsourced transcription, newest technologies, and other deliberations. I encourage you to join these organizations.

A medical transcription typing service provider is ultimately part of a team. As medical language specialists, we can elect to operate in more than one area of the modern-day healthcare team using our medical transcription typing skills.
Good education and knowledge are the keys to this interesting world of words and grammar, medical terminology, anatomy and physiology.

By way of example, medical transcription is a minefield for the layman – The Pituitary gland seems a sad place to start. Moving down the esophagus tube, past the bronchi, a fundoplication may help. You may recognize the sciatic nerve, but what about the varicose veins? The retroverted uterus is a little shy, but the cruciate ligaments are obviously important. platelets are everywhere.

Having sorted out the anatomy, the various ailments were next. Inflammations, human papillomavirus, hypothalamus, Helicobacter, syncopal.

For the surgeons, you have Umbilical hernias, ruptured spleen, fractured zygoma, ectopic pregnancy, bunions, nodes, Arnold Chiari malformation.

Then you need to deal with the stye, cellulitis, cradle cap, solar keratosis, atopic eczema, basal cell carcinoma, melanoma, peptic ulcers.

The transcription typing service provider is part of the team providing accurate and as perfect healthcare as possible. People approach me to help them become transcription typing service providers, but it is not quite so easy as we have already demonstrated. Mecdicine involves an entirely new vocabulary and may as well be a foreign language for the layman.

I began to realize, as many transcription typing service providers do, that there are opportunities out there that employ medical language specialists; “hitting the keyboard” all day is not for all. For some, straight transcription is all that is needed and wanted; for others, it is not.

In risk management, we discuss “active” and “latent” as applied to errors. Active errors occur at the point of contact between a human and some aspect of a larger system and the results are usually felt immediately. Latent errors can be made by any part of the team, and are often removed from the operator’s control. Transcription typing service providers can contribute to latent errors in the healthcare team. Transcription typing service providers are part of the lineup that actively has a role to play in avoiding adverse events involving medication use. We avoid latent errors as editors by checking and double checking what is dictated, not guessing, and being a detective on medications. A knowledgeable transcription typing service provider might know the top 200 medications and common dosages for each. She will double check that what sounds like a “teen” is not a “twenty.” I can’t tell you how many “cheat sheets” and word lists I’ve made for myself over the years, which I still use.

Expressing concerns, questioning, or even simply clarifying instructions requires considerable determination on the part of team members who might perceive their input as devalued or frankly unwelcome. As a transcription typing service provider, be cognizant of the authority gradient! We must persevere to be the best medical transcription typing service providers we can be, speaking out and drawing attention where it needs to be drawn. Suggest changes which cause confusion in reading of the patient record, and document it from three sources! Be discreet (that’s not discrete!) and be professional.

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