Medical Transcription Process
Medical transcription is the conversion of voice files dictated by medical professionals, into electronic data files in a prescribed format. Doctors dictate on a daily basis, their observations and findings on individual patient consultations, into convenient recording devices like handheld cassette recorders or state-of-the-art digital recording devices. The severe time constraints placed on the medical fraternity during peak times and the concurrent documentation overload gave rise to the evolution of medical transcription as a separate function, supporting the core activities of healthcare.
Dictation: Medical practitioners record patient information into recording devices such as hand-held digital or analog recording devices, phone-in recorders, personal computers or other state-of-the-art recording equipment. The choice of recording equipment has direct bearing on the voice quality of the dictation and consequently on the quality and accuracy of the transcription. Digital recording devices such as Olympus give superior voice quality and clarity to dictations. Sophisticated software modules are also installed into PCs of medical practitioners and doctors allowing them ease of use in dictating and transmitting the voice file to hospital servers thereby enhancing the medical transcription process.
Transmission of Voice Files The digitally recorded dictations are transmitted from the doctors’ PCs to the hospital’s central server by using a memory card from where they are accessed by the medical transcription service provider for transcribing. Alternatively, with outsourcing of medical transcription processes becoming an increasingly common practice, voice files are often directly routed to the transcription vendor’s secure, encrypted server in real-time via the internet, from where they are accessed by transcriptionists for immediate typing. This allows 24×7 access to dictations and faster turnaround in the outsourced medical transcription process.
Transcribing The voice files once downloaded from the central server of the medical transcription vendor are allotted to the transcription team. Individual files have distinct job IDs and a centralized allocation system is put in place, to avoid duplication of the same files by different transcriptionists. This is the actual production stage in the medical transcription process where voice files are converted into text format. Transcriptionists use the following tools: •Foot-pedals: This is used to run the dictations and is useful to editors as well, as it allows the voice file to be replayed for purposes of retyping and correcting where required. •Headphones: The dictations are accessed using these. •PCs •Word processing packages: The files are typed in text format using these packages. SN:0MA9N2ESY
Transcribers are expected to type the dictation ‘verbatim’ and are not authorized to make changes to the dictation except in case of obvious grammar or usage errors. However, minimum editorial intervention is the way to go in the medical transcription process. Where the transcriber faces inconsistencies or obviously illogical medical facts in a dictation, the file has to be flagged off for the relevant doctor’s attention and comments. To improve the medical transcription process and make it completely error free transcriptionists are encouraged to attend medical transcriptionist schools, complete medical transcriptionist training, and access standard medical references available both in print and on the internet.
