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Medical transcription is a process in which a medical transcriptionist listens to the audio files of the patient’s medical record made by the physicians or other health care professionals and then accurately transcribes them into medical reports, correspondence, and/or other administrative material. These medical records include (but are not restricted to): history and physical reports, clinic notes, office notes, operative reports, consultation notes, discharge summaries, letters, psychiatric evaluations, lab reports, x-ray reports and pathology reports of the patient. Medical transcriptionists usually listen to the audio files which have been dictated by physicians or other health care professionals, on headphones, by means of a foot pedal to start, pause or stop the file when required, and type the text into a word processor. Once the text is transcribed onto the word processor the MT(s) can edit the document for grammatical or spelling mistakes. Medical transcriptionists then hand over the transcribed documents to the relevant physicians or other health care professionals, for review and signature or correction. These final medial records are added to the patient’s permanent files.
In order to comprehend and correctly transcribe dictated reports, medical transcriptionists must be acquainted with medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. They should have the ability to translate medical terminologies and abbreviations into their full forms. In order to get a greater understanding of the medical terms used the transcriptionists look into the standard medical reference materials which can be printed or electronic; a lot of them are accessible over the Internet. Medical transcription companies must conform with particular standards pertaining to the format of medical records and must pay attention to medico-legal concerns, policies, procedures, laws and ethical requirements in order to keep the patient’s information confidential. A person who wants to take medical transcription as a career must have the following skills set: listening and language proficiency, computer literacy and knowledge of medical terms.
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