Medical transcription

Medical transcription, also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals into text format.The evolution of the transcription dates back to the 1960s. The method was designed to assist in the manufacturing process. The first transcription that was developed in this process was MRP, which is the acronym for Manufacturing Resource Planning, in 1975. This was followed by another advanced version namely MRP2. But none of them yielded the benefit of medical transcription.

However, transcription equipment has changed from manual typewriters to electric typewriters to word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings. Today, voice recognition system (VRS) is increasingly being used, with medical transcriptionists and or "correctionists" providing supplemental editorial services, although there are occasional instances where VRS fully replaces the MT. Natural-language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide (although MTs do).

In the past, these reportings consisted of very abbreviated handwritten notes that were added in the patient's file for interpretation by the primary physician responsible for the treatment. Ultimately, this mess of handwritten notes and typed reports was consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department. Whenever the need arose to review the records of a specific patient, the patient's file would be retrieved from the filing cabinet and delivered to the requesting physician. To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy.

In recent years, things have changed considerably. Filing cabinets have given way to desktop computers connected to powerful servers where patient records are processed and archived digitally. This digital format allows for immediate remote access by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises. Today, we have very fast computers with many electronic references, and we use the Internet not only for web resources but also as our daily working platform. Technology has gotten so sophisticated that MT services and MT departments work closely with programmers and information systems (IS) staff to stream in voice and accomplish seamless data transfers through network interfaces. In fact, many healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants (PDAs), and are now utilizing software on them for dictation.

However, not everything has changed. The conversion of spoken medical language to text is a craft that is difficult to learn and takes time to perfect. Some individuals have a "knack" for it; some will never get it. Technology can and does assist in many ways, but transcription still comes down to people. Even with the transition of MTs to editors for VRS documents, medical-language-interpretation skills will still be imperative for a quality report. MTs welcome this transition as an editor for VRS documents.

An individual who performs medical transcription is known as a medical transcriptionist or an MT, or (less frequently) a medical transcriber. A medical transcriptionist is the person responsible for converting the patient's medical records into typewritten format rather than handwritten, the latter more prone to misinterpretation by other healthcare providers. The term transcriber also describes the electronic equipment used in performing medical transcription, e.g., a cassette player with foot controls operated by the MT for report playback and transcription. In the late 1990s, medical transcriptionists were also given the title of Medical Language Specialist or Health Information Management (HIM) paraprofessional.

There are no "formal" educational requirements to be a medical transcriptionist. Education and training can be obtained through traditional schooling, certificate or diploma programs, distance learning, and/or on-the-job training offered in some hospitals, although there are foreign countries currently employing transcriptionists that require 18 months to 2 years of specialized MT training. Working in medical transcription leads to a mastery in medical terminology and editing, MT ability to listen and type simultaneously, utilization of playback controls on the transcriber (machine), and use of foot pedal to play and adjust dictations - all while maintaining a steady rhythm of execution.

While medical transcription does not mandate registration or certification, individual MTs may seek out registration/certification for personal or professional reasons. Obtaining a certificate from a medical transcription training program does not entitle an MT to use the title of Certified Medical Transcriptionist (CMT). The CMT credential is earned by passing a certification examination conducted solely by the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), as the credentialing designation they created. AHDI also offers the credential of Registered Medical Transcriptionist (RMT). According to AHDI, the RMT is an entry-level credential while the CMT is an advanced level. AHDI maintains a list of approved medical transcription schools .

There is a great degree of internal debate about which training program best prepares a MT for industry work. Yet, whether one has learned medical transcription from an online course, community college, high school night course, or on-the-job training in a doctor's office or hospital, a knowledgeable MT is highly valued.In lieu of these AHDI certification credentials, MTs who can consistently and accurately transcribe multiple document work-types and return reports within a reasonable turnaround-time (TAT) are sought after. TATs set by the service provider or agreed to by the transcriptionist should be reasonable but consistent with the need to return the document to the patient's record in a timely manner.

As of March 7, 2006, the MT occupation became an eligible U.S. Department of Labor Apprenticeship, a 2-year program focusing on acute care facility (hospital) work. In May 2004, a pilot program for Vermont residents was initiated, with 737 applicants for only 20 classroom pilot-program openings. The objective was to train the applicants as MTs in a shorter time period. (See Vermont HITECH for pilot program established by the Federal Government Health and Human Services Commission).