Medical transcriptionists listen to voice recordings that physicians and other healthcare workers make and convert them into written reports.
What they do
Medical transcriptionists, sometimes referred to as healthcare documentation specialists, listen to voice recordings that physicians and other healthcare workers make and convert them into written reports. They also may review and edit medical documents created using speech recognition technology. Transcriptionists interpret medical terminology and abbreviations in preparing patients’ medical histories, discharge summaries, and other documents.
Medical transcriptionists typically do the following:
- Listen to the recorded dictation of a doctor or other healthcare worker
- Interpret and transcribe the dictation into patient history, exam notes, operative reports, referral letters, discharge summaries, and other documents
- Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and consistent in style
- Translate medical abbreviations and jargon into the appropriate long form
- Identify inconsistencies, errors, and missing information within a report that could compromise patient care
- Follow up with the healthcare provider to ensure that reports are accurate
- Submit health records for physicians to approve
- Follow patient confidentiality guidelines and legal documentation requirements
- Enter medical reports into electronic health records (EHR) systems
- Perform quality improvement audits
Traditionally, medical transcriptionists used audio playback equipment to listen to an entire dictation in order to produce a transcribed report, and some transcription is still done this way. It has become more common for medical documents to be prepared using speech recognition technology, in which specialized software automatically prepares an initial draft of a report. The transcriptionist then listens to the voice file and reviews the draft for accuracy, identifying any errors and editing the report, when necessary. Transcriptionists use word-processing and other specialized software to prepare the transcripts, as well as medical reference materials when needed.
Medical transcriptionists must be familiar with medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. Their ability to understand what the healthcare worker has recorded, correctly transcribe that information, and identify any inaccuracies in the transcript is critical to reducing the chance that patients will get ineffective or even harmful treatments. Medical transcriptionists also may need to be familiar with EHR systems.
Medical transcriptionists who work in doctors’ offices may have other duties, such as answering phones and greeting patients.
Administrative and support services includes companies that provide transcription services. Medical transcriptionists may work from home, receiving dictation and submitting drafts electronically.
How to become a Medical Transcriptionist
Medical transcriptionists typically need postsecondary education. Some choose to become certified.
Employers prefer to hire transcriptionists who have completed postsecondary education in medical transcription, which is offered by vocational schools, community colleges, and distance-learning programs. Medical transcription programs are typically 1-year certificate programs, although there are also associate degree programs.
Programs normally include coursework in anatomy, medical terminology, risk management, legal issues relating to healthcare documentation, and English grammar and punctuation. Many of these programs include supervised on-the-job experience. Some transcriptionists, especially those already familiar with medical terminology from previous experience as a nursing assistant or medical secretary, become proficient through refresher courses and training.
Although certification is not required, some medical transcriptionists choose to become certified. The Association for Healthcare Documentation Integrity offers the Registered Healthcare Documentation Specialist (RHDS) and the Certified Healthcare Documentation Specialist (CHDS) certifications. Both certifications require passing an exam and periodic retesting or continuing education.
The RHDS certification, formerly known as the Registered Medical Transcriptionist (RMT), is for recent graduates with less than 2 years of experience and who work in a single specialty environment, such as a clinic or a doctor’s office.
The CHDS certification, formerly known as the Certified Medical Transcriptionist (CMT), is for transcriptionists who hold the RHDS designation. In addition, CHDS candidates must have at least 2 years of acute care experience, including experience handling dictation in various medical specialties.
To maintain certification, medical transcriptionists must complete continuing education requirements every 3 years.
The median annual wage for medical transcriptionists was $33,380 in May 2019. The median wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $22,160, and the highest 10 percent earned more than $51,260.
Employment of medical transcriptionists is projected to decline 2 percent from 2019 to 2029. Technological advances have changed the way medical transcription is done. Speech recognition and electronic health records (EHR) software advances often allow physicians to create some of this documentation in the moment, reducing the need for transcriptionists.
The aging population and growing rates of chronic conditions will continue to increase demand for healthcare services. This will result in a growing number of medical tests and procedures, all of which will require transcription. However, technological advances, such as speech recognition software, allow transcriptions to be prepared by fewer medical transcriptionists.
As healthcare providers seek to cut costs, some will contract out transcription services and not do transcription in-house. Some of this work may be outsourced to other countries, which would reduce domestic employment.
Similar Job Titles
Clinical Medical Transcriptionist, Documentation Specialist, Medical Language Specialist, Medical Secretary, Medical Transcriber, Medical Transcription, Medical Transcription Supervisor, Medical Transcriptionist, Radiology Transcriptionist, Transcriptionist
Court Reporter, Billing/Cost/Rate Clerk, Bookkeeping/Accounting/Auditing Clerk, File Clerk, Legal Secretary
The trade associations listed below represent organizations made up of people (members) who work and promote advancement in the field. Members are very interested in telling others about their work and about careers in those areas. As well, trade associations provide opportunities for organizational networking and learning more about the field’s trends and directions.
- American Health Information Management Association - The American Health Information Management Association (AHIMA) is the leading voice and authority in health information, wherever it is found. Its members work at the intersection of healthcare, technology, and business.
Magazines and Publications
Medical transcriptionists create accurate, clear medical documentation for patient histories, exam notes, operative reports, and other purposes. They listen to recordings made by healthcare workers… and convert them into written reports… and also take documents generated by doctors using speech recognition technology, and closely edit them. Identifying errors, inconsistencies, and missing information is crucial to ensuring patient care isn’t compromised. Transcriptionists translate medical jargon and abbreviations and must understand complex medical terminology. They may enter their reports into electronic health records systems or submit them directly to physicians for approval. Those who work in doctors’ offices may answer phones and greet patients as well. Most medical transcriptionists work full time, though part-time schedules are not uncommon. They work for hospitals, doctor’s offices, and transcription service companies. Some work from home, with more flexible schedules than in typical offices. Reports must be completed accurately and under deadlines, which can make the work stressful. Most transcriptionists have completed either a one-year certificate program, or an associate’s degree in medical transcription. Coursework includes anatomy, terminology, risk management, legal issues, and English grammar. Many programs include supervised on-the-job experience.
Content retrieved from: US Bureau of Labor Statistics-OOH www.bls.gov/ooh,
CareerOneStop www.careeronestop.org, O*Net Online www.onetonline.org