The world of healthcare cannot process without the medical records of the patients. These medical records are considered to be a vital part of a medical and healthcare organization.
Mostly, a patient record is a blend of patients’ history, ailments, symptoms, allergies, lab tests, and the prescribed treatment. Hence, it can be said that the medical record of the patient serves as the bridge between the physician and the patient.
Medical health records are maintained by transcriptionists. Here comes the question: what is a medical transcriptionist and why is a medical transcriptionist required to maintain the medical and healthcare records of an organization? Read more to find out in detail.
What is a medical transcriptionist?
A medical transcriptionist is a healthcare professional that works specifically to ensure that the medical records of the patients are up-to-date and without any error.
Errors or ambiguities in medical records can affect the insurance policy or in severe conditions may result in wrong treatment and healthcare administered to the patient. It is a legal obligation of the medical caregivers to ensure that the records are maintained accurately and updated before the next visit of the patient.
It is the job of the medical transcriptionist to work on the same wavelength as the healthcare professionals so that every visit of the patient is recorded and the complete medical record is up-to-date with reference to the treatment and diagnostics of the patient’s ailment.
A medical transcriptionist is liable to comply with the notes provided by the physician and translate them properly into medical records and organize them as well.
It is the job of a transcriptionist to make sure that all the aspects of a patient’s medical records like the diagnosis, history, and current treatment ate recorded immediately so that the documentation system which is used by the medical and healthcare organization is updated and the physician can access to the updated records before the next visit of the patient or whenever if any medical emergency occurs.
What is the job description of a medical transcriptionist?
The primary job of a medical transcriptionist is to take notes from the doctors, nurses, and other medical professionals after the visit of the patient.
Have a summarized look at the key points of the job description of a medical transcriptionist.
Taking confidential notes and transcription them:
The notes are extremely confidential. These notes are later on transcribed by the transcriptionist into an easy and comprehensive as well as organized record.
Converting the notes into templates
The confidential notes are transcribed into a record which is a template provided by the healthcare organization. As the template can differ from practice to practice as different specialties have different requirements.
Sometimes the transcriptionists might receive a file that is an unedited version and a raw speech-to-text translation. It is the job of the transcript to edit it and format the notes to convert them into comprehensive medical records.
Usage of medical terminologies
The raw notes provided by the healthcare experts need to be transcribed into a more readable format as well as transcribed according to the medical terminologies. This is where the critical thinking and medical terminology knowledge of a medical transcriptionist come in handy. The knowledge and critical analysis skill of a transcriptionist will make the job easier and the percentage of an error will also decrease.
Investigate and clarify conflicting information
While transcribing the confidential notes, if a transcriptionist comes across any kind of information that is conflicting, for instance, the person who is prescribed a certain medicine is allergic to that than they are required to stop the medical record compilation and clarify the error so that the record is updated before the next visitation of the patient.
Medical transcriptionists are required to complete a certain certification program that is an exclusive course consisting of medical terminologies, physiology, anatomy, pharmacology, and diagnostic learning.
Apart from this certification, individuals who want to make a career as a medical transcriptionist, need to have an associate degree as well.
Medical transcriptionists are often known as medical language specialists; as it is very important for them to have an exceptional level of command of punctuation and grammar.
Apart from the above-mentioned essentials, it is very important that the transcriptionist is familiar with the complicated surgical and medical procedures and the terminologies that are used to define them.
Medical transcriptionists must have exceptionally good processing skills so that they can work with different doctors and can understand their accents while decoding the confidential notes sent to them.
The Association for Healthcare Documentation Integrity is the regulatory body that deals with medical transcriptionists. Medical transcriptionists can opt for any more certifications depending upon their experience in the field.
The newly graduated transcriptionists must sit in for an exam in order to become a Registered Healthcare Documentation Specialist (RHDS). All the transcriptionists who have work experience of fewer than two years in the field can sit in this exam.
The registered RHDS transcriptionists are liable to complete 20 hours of education continuation after a span of three years periodically.
Once they have obtained the certification of RHDS then they are eligible to get the certification called Certified Healthcare Documentation Specialist (CHDS). Only Those transcriptionists are eligible to sit this exam if they have an experience of more than 2 years and have been working in more than one specialty practice.
To keep the certification of CHDS, the medical transcriptionists must complete 30 hours of continuing education in the span of three years otherwise they would have to take the exam again.
Medical transcriptionists are the ghost warriors of the medical industry. They work behind the scenes ensuring that the medical professional is providing you accurate treatment and diagnosis based on the medical record compiled by them.
Medical practitioners often request medical records from transcriptionists to ensure that they are being maintained with accuracy.
The Health Insurance Portability and Accountability Act (HIPAA) has given the right to physicians to check their medical records whenever needed.