The profession of a medical transcriber is so overlooked that many people are unaware of its existence until they google answers to the question: What is a medical transcriptionist?
As you may know, many professional roles support the healthcare industry, such as nurse practitioners, physicians, medical assistants, and other healthcare service providers. Among these professionals, medical transcriptionists are most often neglected by patients because they generally work behind the scenes. But does that mean a medical transcriptionist’s work is insignificant? No.
Keep reading to learn everything about the profession of a medical transcriptionist and how to become one.
What Is Medical Transcription?
What is a medical transcriber?
Medical transcription involves transcribing medical records and dictations by nurses, doctors, and other healthcare practitioners. Medical transcription is also known as MT (not to be confused with Machine Translation, abbreviated as MT). These medical records document everything from a patient’s symptoms, surgical notes, medical histories, and discharge summaries to results of physical examinations and diagnostic tests. These documents are generally used for communication among healthcare providers, legal documentation, insurance, billing purposes, etc.
What Does a Medical Transcriptionist Do?
As a type of transcriptionist, a medical records transcriptionist transcribes medical records and documents for clinics, private practices, hospitals, and other healthcare facilities. Medical transcribers listen to recordings made by healthcare professionals, such as doctors or nurses, and convert them into written reports, which become part of the patient’s medical file. They must have profound knowledge of medical terminology, anatomy, and pharmacology and an understanding of healthcare regulations and procedures.
A medical transcriber needs to be accuracy-oriented with great attention to detail because even the tiniest error in medical records can lead to serious consequences. Medical information features a sensitive and urgent nature. This is why medical transcribers must work efficiently under pressure and meet tight deadlines.
Where Do Medical Transcriptionist Work?
Medical transcribers usually work for specialized transcription companies or various healthcare organizations such as hospitals, private practices, clinics, etc., as in-house medical transcribers, outsourced online medical transcriptionists, independent contractors, medical transcription editors, quality assurance specialists, or speech recognition editors based on different job requirements or settings.
- Transcription companies:
Many healthcare organizations entrust their transcription work to professional transcription companies that employ full-time or part-time medical transcribers to complete transcription tasks. Medical professionals can focus on developing a better treatment plan and decision-making process in the follow-up care.
- Hospitals:
Some hospitals have medical transcription departments staffed by remote transcription workers or full-time transcriptionists.
- Clinics:
Medical transcribers are also required by smaller healthcare facilities such as private practices or clinics to handle medical documentation.
- Work from home:
Technological advancement has made remote working a reality. Medical transcription is among thousands of flexible freelance work. Online medical transcriptionists can work directly for individual clients or contract with medical transcription companies.
- Other medical transcriber work environment:
- Doctors’ offices
- Health and wellness centers
- Medical schools
No matter their work settings, medical transcribers must have specialized knowledge across several medical fields, from anesthesiology to urology. They often complete training programs to gain specialized knowledge in medical transcription or obtain a medical transcriptionist certificate.
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How to Become a Medical Transcriptionist?
If you’ve come from a medical background and find transcription work well-suited, how do you become a medical transcriptionist?
Here are some of the most important medical transcriptionist requirements:
- Educational requirement: Holding a high school diploma or a general equivalent diploma is the primary requirement for a medical transcriber.
- Medical transcription training: Register for medical transcription training programs to get instructions in medical terminology and abbreviations, keyboarding skills, and using transcription software.
- Gaining experience: Employers tend to consider candidates with previous working experience in medical settings or with medical documentation. Before applying for medical transcription work, try to work for healthcare facilities in roles that involve medical record-keeping, such as an administrative assistant or medical secretary.
- Medical transcription certification: Although not a mandatory requirement, obtaining a medical transcription certificate can prove that you are equipped with the necessary knowledge and competency in medical transcription. Organizations that provide medical transcription certification programs include the AHDI (the Association for Healthcare Documentation Integrity) and the AHIMA (American Health Information Management Association).
- Essential Skills: Good listening and language skills are critical for medical transcribers. You can enhance these skills by listening to medical dictations and practicing typing faster without sacrificing accuracy.
Medical Transcription Certificate
Once an individual completes a medical transcription training program, they will receive the medical transcription certificate recognizing that they have obtained the knowledge and skills required for the medical transcription work. Lasting from months to one year, these programs concentrate on training in medical terminology, pharmacology, anatomy and physiology, word processing, grammar and punctuation, keyboarding, and the usage of medical transcription software.
In some states in the US, only a certified medical transcriptionist can legally handle medical documentation and dictations. Even medical transcription certificate is not required in other states; employers prefer a certified medical transcriptionist to those without a certificate when vetting job applicants for transcription work.
There are two different types of medical transcription certifications offered by the AHIMA for HDS (healthcare documentation specialists) – RHDS (Registered Healthcare Documentation Specialist) and CHDS (Certified Healthcare Documentation Specialist).
Both certifications have their own eligibility requirements and stand for different levels of expertise. RHDS is an entry-level certification, while CHDS is more of an advanced-level one.
An individual must have a minimum of two years of on-the-job experience in healthcare documentation or completed an AHIMA-approved medical transcription training program to be eligible to sit for the RHDS exam, which tests his/her knowledge of medical terminology, pharmacology, anatomy, and physiology, healthcare documentation formats and style, and grammar and punctuation, etc.
The test takers of the CHDS exam are experienced healthcare documentation professionals with proven experience in multiple areas of healthcare documentation, such as acute care, radiology, pathology, and multispecialty clinics. Before being eligible to sit for the CHDS exam, they must meet specific educational and experience requirements and pass a comprehensive exam covering advanced topics related to healthcare documentation, regulatory compliance, performance measurement, and quality assessment.
You can choose your medical transcription certification exam according to your particular needs and level of expertise.
To Wrap Up
So what is a medical transcriptionist? In short, a healthcare professional converts the dictations of other healthcare professionals, such as doctors and nurses, to a written format. Keeping an accurate and complete text-based record is essential in the healthcare industry because healthcare providers, insurance companies, etc., can use this documentation to communicate better during the patient’s treatment, billing, and reimbursement processes. These records ensure proper diagnosis, treatment, and continuity of patient care.
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