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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The fast and easy way to explore a medical transcription career
Flexibility is one of the most enticing aspects of a career in medical transcription. Perfect for in the office, at home, or on vacation, medical transcriptionists can often create lifestyle-appropriate schedules. The transcription field also appeals as a part-time, post-retirement income source for ex-healthcare-industry workers. If you're interested in a career in this growing field, Medical Transcription For Dummies serves as an accessible entry point.
With guidance on getting through training and certification and exploring opportunities within the myriad different kinds of employment arrangements, Medical Transcription For Dummies gives you everything you need to get started in medical transcription.
- Guides you on getting though medical transcription training and certification
- Includes expert advice and tips on how to approach complex medical jargon and understand procedures
- Plain-English explanations of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments
Whether used as a classroom supplement or a desk reference, students and professionals alike can benefit from Medical Transcription For Dummies.
Das E-Book können Sie in Legimi-Apps oder einer beliebigen App lesen, die das folgende Format unterstützen:
Seitenzahl: 485
Veröffentlichungsjahr: 2012
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Medical Transcription For Dummies®
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Table of Contents
Medical Transcription For Dummies®
by Anne Martinez
Medical Transcription For Dummies®
Published byJohn Wiley & Sons, Inc.111 River St.Hoboken, NJ 07030-5774www.wiley.com
Copyright © 2013 by John Wiley & Sons, Inc., Hoboken, New Jersey
Published simultaneously in Canada
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Library of Congress Control Number: 2012952197
ISBN 978-1-118-34307-4 (pbk); ISBN 978-1-118-45052-9 (ebk); ISBN 978-1-118-46105-1 (ebk); ISBN 978-1-118-46107-5 (ebk)
Manufactured in the United States of America
10 9 8 7 6 5 4 3 2 1
About the Author
Anne Martinez and medical transcription met for the first time in 2005. She had no idea what she was getting in to. Desiring a little “regular work” to round out her self-employment income, she took to the Internet and began researching work-at-home jobs. Medical transcription seemed a perfect match for her love of language and interest in all things medical. Her first step was to look for an introductory how-to book, but there wasn’t one. She determined on the spot that she would write it; first, though, on to becoming a medical transcriptionist!
In 2006, after about a year of intense studying at home, Anne graduated from the M-TEC online medical transcription program. Soon thereafter, she was employed full time (despite her original intention to work part time) and garnering the benefits of health insurance she didn’t have to pay for entirely herself, a steady income, and actual paid vacation days! She later switched to a part-time independent contractor position to gain a more flexible schedule and take advantage of additional opportunities.
During her time as an MT, Anne transcribed many, many medical reports for hospitals and physician groups, including history and physical exams, discharge summaries, operative reports, consultations, office notes, and an amazing variety of diagnostic procedures.
She’s currently wrapped up in writing projects and managing her successful website, GoCertify (www.gocertify.com), so she’s put her MT career on hold. However, it stands ready in the wings, waiting for her return should the need arise.
Dedication
To all the hockey players I’ve ever played with or against, especially the teams I’ve been honored to be part of: May your skates always be sharp, the ice hard, and the Zamboni working.
P.S. May your medical records contain only routine office notes.
Author’s Acknowledgments
A book is rarely the fruit of a single author, and this one is no different. Many people participated in shaping it and packing it with the most relevant and accessible information possible. My first shout-out goes to Patty Urban, my go-to resource for everything MT since practically day one of my MT career and the natural pick to serve as technical editor of Medical Transcription For Dummies.
To Ann Morgan and the other MTs who hang out at the Medical Transcription Networking Corner on Facebook, thank you for sharing your experiences and opinions on all things MT. Carol Butler, Cindy Leach, and Debi Shope made time to contribute thoughtful MT wisdom and advice despite intensely busy schedules.
Others who were instrumental to the creation of this book include Lindsay Lefevere, who gave me the chance to write the book I’ve been thinking about since I signed up for my first MT course, and Matt Wagner, without whom I never would have met Lindsay. Elizabeth Kuball, project editor extraordinaire, dedicated her time and expertise to make sure this book became the best it could be. Many thanks also to Steve Elliot, who once again pointed me in the right direction when I told him there was a book I wanted to write. Extra kudos to Sara Devine, for relentlessly tracking down permissions and helping keep the rest of my work life running while I focused on this book.
Special thanks to Dan McGovern for his support, encouragement, and friendship that helped carry this book and its author through an onslaught of deadlines, and to my teenage children, Evan and Rebecca, who basically surrendered me to this process and largely took care of themselves for the duration.
Publisher’s Acknowledgments
We’re proud of this book; please send us your comments at http://dummies.custhelp.com. For other comments, please contact our Customer Care Department within the U.S. at 877-762-2974, outside the U.S. at 317-572-3993, or fax 317-572-4002.
Some of the people who helped bring this book to market include the following:
Acquisitions and Editorial
Project Editor: Elizabeth Kuball
Executive Editor: Lindsay Sandman Lefevere
Copy Editor: Elizabeth Kuball
Assistant Editor: David Lutton
Editorial Program Coordinator: Joe Niesen
Technical Editor: Patricia Urban
Senior Editorial Manager: Jennifer Ehrlich
Editorial Manager: Elizabeth Kuball
Editorial Assistant: Rachelle Amick, Alexa Koschier
Cover Photos: © Feng Yu / iStockphoto.com
Cartoons: Rich Tennant (www.the5thwave.com)
Composition Services
Project Coordinator: Patrick Redmond
Layout and Graphics: Melanie Habig, Jennifer Henry, Andrea Hornberger
Proofreaders: Joni Heredia, Jessica Kramer
Indexer: Steve Rath
Publishing and Editorial for Consumer Dummies
Kathleen Nebenhaus, Vice President and Executive Publisher
Kristin Ferguson-Wagstaffe, Product Development Director
Ensley Eikenburg, Associate Publisher, Travel
Kelly Regan, Editorial Director, Travel
Publishing for Technology Dummies
Andy Cummings, Vice President and Publisher
Composition Services
Debbie Stailey, Director of Composition Services
Introduction
You’ve probably heard that medical transcription is a flexible career that you can do from home. Perhaps you’re attracted to the idea of being part of the drama and intimate details of medical care, and medical transcription sounds like it would be very interesting work. Maybe you just want something, anything, you can do from home to earn a buck, and you’re wondering if medical transcription could be it.
Despite what some advertisements might lead you to believe, it’s not true that anyone willing to take a course can become a medical transcriptionist (MT) and earn big bucks working from home. It is true that it’s interesting, challenging, and often flexible work. Many MTs do work from home. You can prepare for and launch an MT career without ever stepping out your front door, if you want to. For some people, it’s a great career option, but it’s not the right choice for everyone.
About This Book
This isn’t a textbook about how to become an MT. You don’t need to read it cover to cover or even in order. Dip into the part you need, when you need it. Come back later and dip into a different section when you need that. Consider this a quick study guide, reusable reference, and career companion.
There’s a lot of information, and even more misinformation, available about working as a medical transcriptionist. This book is here to help you sort fact from fiction, so you can decide if you want to become an MT, and if so, how to go about it. It’s also designed to stand beside you and answer the questions that most commonly pop up after you get on the job.
Conventions Used in This Book
I don’t use many conventions in this book, but I do use a few:
When I define a new term, I italicize it. You can find the definition nearby (often in parentheses).
I use monofont for web and e-mail addresses. Note: When this book was printed, some web addresses may have needed to break across two lines of text. If that happened, rest assured that we haven’t added extra characters (such as hyphens) to indicate the break. So, when using one of these web addresses, just type in exactly what you see in this book, pretending as though the line break doesn’t exist.
What You’re Not to Read
The shaded boxes that appear here and there are sidebars. They include extra information that’s interesting or fun. The material in them isn’t essential to understanding the topic at hand, and you can bypass them without missing out on key concepts.
The Technical Stuff icon identifies extras included for people who like to know the details behind things. If you’re not one of them, it’s okay to zip right past.
Foolish Assumptions
I figure you’ve probably picked up this book for one of the following reasons:
You’re thinking about becoming an MT and you want to know what the job entails and how to get started.
You’re already an MT student and you picked up this book to help you get off to a flying start.
You’re a working MT who’s as obsessed with learning and growing as you’ve always been.
I also assume that you want to get straight to business and not waste time lollygagging around.
How This Book Is Organized
This book is broken into parts that parallel the journey to an MT career. It starts at the beginning with career exploration and moves on to identifying and mastering practical skills and then to landing and managing an MT job. The final part provides reference materials you can use to help you on the job.
Every chapter in Medical Transcription For Dummies is designed to be entirely self-contained. You can go through them in order or jump straight to whatever you need at the moment. This is one time when you can have something both ways.
Part I: So, You Want to Be a Medical Transcriptionist
Before diving into a career in medical transcription, you’ll want to know exactly what’s involved and what to expect. This part will give you the basis to decide if medical transcription is a realistic career option for you, and if so, how to get off to a running start. It starts with an inside look at what MTs do on a daily basis and what it really takes to break into the field. You’ll also survey the types of places MTs work and how much you can expect to earn. One of the most crucial foundations to a successful MT launch is getting the right training. This part identifies what that should include so you don’t spend good money on bad training.
Part II: Getting the Job Done: Medical Transcriptionist How-To
This is where you’ll meet and build the technical skills that lie at the heart of a successful medical transcription career. You can put yourself through medical terminology boot camp and study up on the mechanics of formatting medical reports following accepted standards. There’s also a chapter packed with tips for deciphering difficult dictation and tricks for coping with mumbly mouthed dictators. In medical transcription, time is (your) money. The chapters on effective referencing and speed-boosting techniques will help you lay in the skills so you can be fast and accurate.
Part III: Looking At the Types of Reports You’ll Transcribe
This part takes you on an in-depth tour of individual reports and how to transcribe them. Each member of the “Big Four” family of reports gets its own detailed chapter. You also step through another half-dozen report types you’re likely to encounter.
Part IV: Employment Matters: Landing and Managing a Medical Transcriptionist Job
MT skills are useful only if you can put them to work! This part offers tips and advice to help you choose and land your first MT job — and the one after that. There’s a chapter explaining the technical details of outfitting a home office. If you opt to work as an independent contractor (IC), you’ll want to read the chapter on financial matters, for sure.
Part V: The Part of Tens
If you’re a fan of top ten lists, this is the part for you. It includes ten factors that contribute to MT success, busts ten common myths about medical transcription work, and introduces you to ten online resources that stand head and shoulders above the rest.
Part VI: Appendixes
Good references are among an MT’s best allies. The glossary, transcription examples, and sample reports in this part are here for you to turn to when you need a little help. They don’t eradicate the need for dedicated reference books, but they do provide a unique cross-section of material that zeroes in on the items experience shows you’re most likely to need.
Icons Used in This Book
As you go through this book, you’ll see the following cute little icons in the margins. Here’s what they mean:
The Tip icon points out a handy technique or shortcut that can save you time or help you avoid frustration down the road.
When you see the Remember icon, it’s pointing out a key concept you’ll want to file away in your brain for future use.
The Warning icon alerts you to potential pitfalls and things that can cause serious trouble. When you see it, pay extra-careful attention to the text nearby.
The Technical Stuff icon points out technical tidbits that are interesting but not absolutely necessary to understanding the topic at hand. If you want all the details you can get, read them. If you want just the basics, skip them.
Where to Go from Here
By all means, jump into this book anywhere you’d like. If you’re in an exploratory phase, Chapter 1 is the obvious place to begin, but you may also head on over to the Part of Tens and start by clearing up ten myths about medical transcription. If you want to take a gander at some actual medical reports, Appendix C has you covered.
If you’re burning to steep yourself in medical terminology as quickly as possible, the boot camp in Chapter 5 is specifically for you. If difficult dictators have you hog-tied, Chapter 7 will help you decipher what they are (in theory) saying. Working MTs and students near graduation may be particularly interested in the “faster, faster” productivity techniques in Chapter 9.
Thinking about going the independent contractor instead of employee route? Be sure to read Chapter 19 so you can get your financial ducks in a row and keep them there.
You also can read this book in the ordinary, straightforward manner: Start at the beginning and keep going until there are no pages left to turn.
Part I
So, You Want to Be a Medical Transcriptionist
In this part . . .
Time to cut through the hype and clutter and get to the facts on a medical transcriptionist career. As a medical transcriptionist, you’ll make critical contributions to patient care that go far beyond typing fast. This section gives you an inside look at what medical transcriptionists do on a daily basis and the personal traits and professional skills required to get the job done. It also surveys where the jobs are, how much they pay, and how to get the training needed to break into the field.
Chapter 2
The What, How, Who, and Why of Medical Transcription
In This Chapter
Surveying the field of medical transcription
Getting the lowdown on how medical records are transcribed
Considering if you have what it takes to be a successful medical transcriptionist
Identifying the benefits of working as a medical transcriptionist
You may have seen ads or attended a seminar that promised you can be trained as a medical transcriptionist and work from home (in your pajamas if you like) within weeks. Surely you can become a medical transcriptionist with minimal training — after all, it’s just typing what somebody says, right? Actually, no. Medical transcriptionists (MTs for short) create records and reports that are used to make critical decisions about patients’ healthcare. They’re experts in medical language, driven to pursue perfection, and able to apply critical thinking and research skills deftly and quickly.
Medical transcription is a lot more complex and quite a bit more challenging than many people expect. In this chapter, I explain how medical transcriptionists transform words spoken by a medical professional into a formal medical record. You find out what goes on between the moment the words leave a dictator’s lips and the time it becomes a permanent part of a patient’s medical record. You explore the skills and personality traits that contribute to a successful and enjoyable medical transcription career and complete a short self-assessment to determine if you and medical transcription are a good match. Finally, I fill you in on the advantages of a career in medical transcription.
What Medical Transcriptionists Do
Medical transcriptionists are supposed to produce the most accurate and clear healthcare documentation possible, often on very tight deadlines. And they must do so even if the physician has a heavy accent or dictates while gulping down dinner, and even if loud conversations, a wailing baby, or medical alarms are going off in the background.
Under such conditions, the MT must reconcile the duty to transcribe verbatim (exactly what the doctor says word for word) with the responsibility to produce high-quality reports, and juggle both of those tasks with the reality of a job that usually pays on production: The faster you go, the more you earn.
If the MT introduces a mistake into a patient’s medical record, such as mistyping a medication name or dosage, the results can be serious — even deadly. If the dictator makes a mistake and the MT catches it, the MT averts a potential disaster for that patient.
When you understand the true challenges and responsibilities associated with being an MT, the job can quickly go from easy to intimidating. Yet these same challenges and responsibilities make the job interesting and rewarding.
Officially: It’s about documentation
The job of a medical transcriptionist is to convert spoken medical information into formal medical records. The dictations cover everything from routine healthcare to life-threatening emergencies. The collection of the resulting documents becomes the patient’s medical history. Health professionals rely on them when assessing a patient’s past care, current status, and future needs.
Officially speaking, there are two formal, published descriptions of what functions a medical transcriptionist performs. The job description the U.S. Department of Labor uses is pretty slim:
Transcribe medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries. Transcribe dictated reports and translate abbreviations into fully understandable form. Edit as necessary and return reports in either printed or electronic form for review and signature, or correction.
Don’t hold the brevity of this against the Department of Labor writers, though; they only get a single a paragraph to summarize an entire profession.
The second formal medical transcription job description is published by the Association for Healthcare Documentation Integrity (AHDI). This job description (which is too long and detailed to reproduce here) organizes the MT profession into three career levels and delves into the expected knowledge and job functions of each. It’s updated from time to time; the current version is available on the AHDI website (www.ahdionline.org).
These official descriptions are deliberately succinct, and that means they summarize in generalities at the expense of particulars. They don’t have room, for example, to mention that a lot of the communication between healthcare providers and, thus, a lot of work done by transcriptionists revolves around a set of reports dubbed the “Big Four”:
History and Physical Examination (H&P): The standard medical intake report describing who you are and what your problem is. These reports are dictated in new-patient office visits and acute-care facilities.
Consultation: What the specialist says before he sends the bill.
Operative Report: What happened under the knife.
Discharge Summary: How it all worked out in the end.
Although the Big Four make the biggest splash, there is a virtually endless variety of reports to transcribe. Which ones a particular MT encounters on a regular basis depends on where he works. Other common report types include the following:
Office/clinic note: Summary of an office visit, often just a paragraph or two per patient and often dictated in a series as each patient is seen.
Independent medical evaluation (IME): An in-depth assessment of past treatment and current condition, used to determine eligibility for workers’ compensation and insurance benefits, as evidence in personal injury or negligence lawsuits, and in other legal proceedings. As you may expect from any document related to potential litigation, these reports can go on for pages. They’re also often quite interesting.
Diagnostic report: Findings on X-rays, ultrasounds, CT scans, MRIs, echocardiograms, sleep studies, and other diagnostic procedures. They’re generally short and quantitative.
Emergency room reports, physical therapy evaluations, psychiatric assessments, birth and death summaries, and more.
MTs take steps to enhance the clarity of reports as they transcribe them, including
Expanding medical acronyms, many of which can have different meanings depending on context
Applying rules of English grammar and punctuation, regardless of whether the dictator follows them
Formatting the reports following standard guidelines and facility-specific rules
Tracking down and flagging potential errors
In addition to transcribing spoken dictation, MTs are increasingly handed the task of proofreading, editing, and correcting medical documents created using speech recognition technology (SRT). MTs also must understand and comply with patient privacy and confidentiality guidelines, including the federal HIPAA regulations that define national standards for the management and protection of health information.
These activities comprise the public face of MT work. They’re the aspects most apparent to those on the outside looking in.
Unofficially: Critical contributions to patient care
The overriding mission of an MT is to produce a medical record that is clear and accurate, even if the original source of information is not. It requires employing personal judgment and no small amount of patience and determination. If all medical dictators spoke clearly, used good dictation equipment in proper working order, clearly enunciated any jargon they use, and never made mistakes, medical transcription would be largely a matter of typing fast and referencing accurately. Modern computer programs could do it virtually unaided. However, the real world is rarely neat and tidy, and neither is dictation.
MTs clean up after dictators who are hampered by their equipment or surroundings, fatigued, or just plain bad communicators. They do it carefully, thoroughly, and often under tight deadlines. MTs apply knowledge of medical terminology, surgical procedures, lab tests, medications, and human anatomy and physiology to correctly transcribe often complex medical encounters. They detect and correct mistakes. An MT is sometimes the difference maker between a barely legible medical record and crystal clear one.
A rose by any other name: Alternate job titles
In an effort to reflect the changing responsibilities and variety of important roles medical transcriptionists fill, alternative job titles sometimes are used:
Clinical documentation specialist
Medical language specialist (MLS)
Healthcare documentation specialist
Healthcare documentation practitioner
Health information professional
Medical speech recognition editor
Medical transcriptionist (MT) is still the most widely used job title, though.
The fellow human being whose care is being recorded is the ultimate beneficiary of an MT’s efforts, but not the only one. Many dictators recognize this and appreciate the extra layer of support and even safety MTs provide. High-quality healthcare documentation is critical to the survival of healthcare facilities, too. It’s central to their ability to
Increase patient safety
Comply with extensive state and federal regulations
Reduce risk exposure and potentially lower liability costs from lawsuits
Obtain payment from health-insurance providers, which want to know exactly what treatment a patient has received and from who before coughing up a dime
How Medical Transcription Works
Back in the day (sometime between the Stone Age and the dawn of the Internet), dictation was done into tape recorders or over the phone (to a bigger tape recorder). Transcriptionists would then play back the tapes through headphones, using transcription equipment that allowed them to start, stop, fast-forward, and rewind the tape with a foot pedal, and type what they heard using IBM Selectric typewriters. They were masters of wielding Wite-Out and typewriter correction tape.
Making corrections always has been and always will be part of an MT’s tasks. Dictators often don’t dictate in a straight line from beginning to end, which can make producing a coherent technical report challenging. Even when they are speaking clearly and not with a mouthful of crackers, they tend to say something, then back up and change it, resume where they previously left off, pause and ask the transcriptionist to insert a new paragraph in the middle of the report, correct a medication dose they dictated earlier, get interrupted, forget what they already said and repeat it, and so forth. They simply don’t go straight from point A to point B.
Although the tools have changed, the transcription process remains largely the same. Dictation is done into digital recorders or over the phone (to a bigger digital recorder). Transcriptionists then play back the recording through headphones, using a foot pedal or keyboard controls that allow them to start, stop, fast-forward, and rewind the recording, and perhaps most important, replay it very slowly. They type what they hear into a computer. They’re masters of macros and keyboard commands that search and replace and insert and delete text, and thank goodness for spell-check. Dictators still often take side trips in the middle of a report, but it’s easier to deal with them.
The journey a report travels from patient encounter to permanent medical record goes like this:
1. A patient visits a healthcare professional or undergoes a medical or diagnostic procedure.
2. The care provider uses a voice-recording device to create a verbal record of the encounter or diagnostic results. The dictator may speak into a handheld recorder, use a phone-in system, or dictate directly into a computer terminal.
3. The report is transmitted over a secure connection to a central server, where it is placed in a “pool” and then funneled into a medical transcriptionist’s job queue.
4. The medical transcriptionist accesses the voice recording, listens to it, and transcribes it into the required format.
5. The transcribed report may be “put on hold” to undergo a quality assurance (QA) process.
6. The report is transmitted back to the medical facility and becomes a part of the patient’s medical record.
When a report arrives back at the originating facility, it’s ideally reviewed by the dictator for accuracy, signed, and added to the patient’s medical record. Some dictators don’t review their transcribed reports, and those are tagged as “dictated but not read” and receive an electronic version of the dictator’s signature. Figure 2-1 illustrates the flow of information from dictator to transcriptionist and back again.
Today the vast majority of MTs work from home and access their job queue remotely using a personal computer and an Internet connection or dedicated telephone line.
With increasing frequency, Step 4 incorporates a detour via speech recognition technology (SRT). Instead of an MT listening to a voice file and creating the report, a computer program takes a preliminary whack at it. The text translation and original audio file are forwarded to an MT, who listens to the voice file and compares it to the text translation, editing as needed to produce the final report. In theory, this approach is faster and requires less skill than transcribing without computer intervention. Experienced MTs, however, report otherwise. Despite the advances in SRT, the editing required can be extensive. The MT must listen to the entire voice file to check for misinterpretations or phrases that were dropped entirely. Minor oddities and major errors must be recognized and remedied. At times, the SRT detour results in greater speed and efficiency, but it also can have the opposite effect.
Figure 2-1: The cycle of medical transcription.
The most satisfied and successful MTs are adaptable and embrace technological change rather than do battle with it. The growing use of SRT is a prime example. Although SRT won’t eliminate the need for traditional transcription any time soon, many MTs serve as speech recognition editors at least some of the time.
Who Makes for Good Medical Transcriptionists: The Traits You Need
Working as a medical transcriptionist isn’t for everybody. The entry requirements are relatively low when compared to professions that require a college degree or extended apprenticeships and internships, but you’ll still have to invest substantial time and money to obtain the training needed to break into the field. You also may have to lay out some cash for equipment and supplies. Before you clear out your schedule and open your wallet, take the time to assess how your personality and skills match up with the demands of the job.
Knowledge of medical terminology and procedures
