What Do Medical Records Transcriptionists Do?

Introduction:

The medical records transcriptionist is an integral part of the healthcare system and requires people with a high degree of computer skills, speed and accuracy at typing, good hearing, and the ability to work largely unsupervised.

The medical records transcriptionist should have a working knowledge of basic medical terms, especially anatomy and physiology, and disease diagnosis and treatment processes. In addition, the transcriptionist will have excellent keyboard skills and organizational ability.

Accuracy is essential in the work of the transcriptionist. Good proof reading skills are also a must. The records the transcriptionist types play and important part in patient treatment and health.

JOB DESCRIPTION

A full-time medical transcriptionist will work a forty-hour week sitting at a keyboard, recording patient histories from dictated, recorded, or written information. The job is simple but there are the pressures of speed and accuracy to contend with. The transcriptionist must be a strong speller and be able to enter the proper medical terminology with precision. The medical records transcriptionist (MRT) will generally use a headset with a pause mechanism to listen to reports and transcribe them by means of a word processor. The MRT must know medical terminology, anatomy and physiology, diagnostics and pharmacology, and the various treatment evaluations. Furthermore, the MRT will have to recognize medical abbreviations and be able to expand them into the proper terminology. With experience, the MRT will be able to identify mistakes in records and make the proper corrections. Accuracy is vital to the MRT because mistakes in health record transcriptions might very easily cause harm to the patient.

Ideally, the medical records transcriptionist will work in a quiet atmosphere with comfortable, undisturbed surroundings. Often the transcriptionist works from a home office and sends the reports back to the doctor, clinic, hospital, lab, or insurance company via electronic transfer. Recently a number of companies have sprung up which contract for medical records transcription and hire home-based typists to do the work. For this reason, the medical records transcriptionist must be a self-starter and able to work without supervision. In the case of a home based independent contractor who works directly with physicians or other healthcare professionals or facilities, the MRT may be on call for irregular hour assignments.

Generally speaking, the work will involve transcribing patient medical histories, surgical procedure notes, medical consultations, and discharge information. Some transcriptionists who have experience in a specific healthcare area may specialize in that area of medical record transcription. The potential hazards of this type of work involve sitting in the same position for long periods of time; eyestrain from hours looking at a computer screen; hand, arm and wrist problems as in carpal tunnel syndrome from hours of managing a keyboard; and back and neck problems. REQUIREMENTS

There are various training programs available for this position which may run from two months to two years, the latter resulting in an associate degree. Fundamental to the training is accurate keyboarding and computer skills along with training on various means of transcribing from recorded media. Medical and legal concept courses will also be included in the training program. The transcriptionist will need to develop proofreading and editing skills as well as the typing skills needed to do the job. Ideally, the training for a medical records transcriptionist will include an internship within a medical environment. There are certification programs after a qualified candidate passes the certification examination to become a CMT (certified medical transcriptionist).

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WORK ENVIRONMENT

In those cases where the MRT works in a healthcare office, the surroundings are well lit and quiet with disturbances kept to a minimum. However, as more and more of this work is being farmed out to Medical Transcription Companies, more MRTs are working out of home offices. In the healthcare office, there is often the advantage of working under the supervision of a medical information supervisor or medical records technician. The home based MRT may find that there are many distractions that hinder the production of quick and accurate transcriptions.

MEDICAL RECORD TRANSCRIPTION COMPANIES

Rapidly growing healthcare related companies are the medical record transcription companies which offer the healthcare industry electronic transcriptions stored in a secured ID database. Many of these companies hire transcriptionists who work from their homes. In addition to lowering costs for physicians and other users of the service, the medical record transcription company guarantees a fast turn around of the transcribed records, usually within twenty-four hours. Physicians and others using the service can view written records and print them out in their own offices. What all this means in the home based MRT must learn and become proficient in the software of the company. This means the MRT is no longer simply a typist but must also master the electronic software for performing the job that meets company standards.

Prerequisites for obtaining a position as an MRT with such companies varies from one to the other, however, on the average a home based applicant can expect to need at least three years of medical records transcription experience. An office based employee will be expected to have two years of experience. Training for these company positions assumes prior knowledge and experience and will last only for one week. Some companies will offer further training for those who stay a long time on the job. Advancement is possible with some companies where the MRT can be promoted to account management or quality control assurance. Part time home based MRTs are hired as independent contractors and are not usually eligible for company benefits.

JOB OPPORTUNITIES

Demand for MRTs, according to recent studies, will continue to grow faster than the national average for all other occupations through the year 2014. Attempts at sending medical records for transcription abroad have not proven successful as the transcriptions then have to be edited for corrections in English grammar and usage. MRTs are usually paid by production which averages in the area of $11.00 per hour.

SUMMARY

A position as medical records transcriptionist is ideal for the self-starter and detail oriented typist. It further allows for such choices as working part time at home rather than commuting to an office. It does not require the same level of people skills expected of a medical secretary and working hours can be somewhat flexible. The disadvantages are the physical problems that might arise from doing this type of work for long hours on a daily basis and the stress caused by the pressures of speed and accuracy.