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Medical Transcription FAQs
What does
a medical transcriptionist do exactly?
What do doctors
dictate?
So, do MTs
just type what they hear?
How do I learn
all this stuff?
Does it pay
the bills?
Is this really
a legit work-at-home opportunity?
Why do I always
see advertisements touting too-good-to-be-true starting salaries
with pictures of women sitting at the computer with kids on their
lap?
A medical transcriptionist's job, in
basic language, is to turn a doctor's dictated speech into a properly
formatted and properly spelled text document. There are many
ways of going about that task which depend on the method the doctor
uses to dictate, the method used to get the audio to the transcriptionist,
and the method used to get the completed document back to the doctor.
Doctors dictate about anything from
runny noses to highly specialized and technical surgical procedures,
as well as letters to other doctors, letters to patients, notes
to schools to get students out of PE or other activities.
Radiologists and pathologists dictate test results and imaging results.
You may have to transcribe echocardiograms, pulmonary function tests,
sleep studies, physical therapy progress notes, and even expiration
(death) summaries.
Not if they want to stay employed for
any length of time. It is an MTs job, even on the most verbatim
of accounts, to be able to understand the terminology, correctly
spell the terminology, fix glaring grammatical errors (verb tenses,
etc.), correctly punctuate, spot any inconsistencies (to include
anything from male/female, left/right to incorrect or impossible
medication dosages).
If you are not asked to transcribe
verbatim, it then becomes your job to perform all the tasks listed
above in addition to rephrasing difficult sentences, moving text
around to fit under the correct headings, deleting redundancies,
expanding acronyms (you must know what those acronyms stand for),
and any other thing that is requested of you on that particular
account.
An MT may also be required to find
the correct spelling of doctors' names, ensure a carbon copy of
the report goes to whomever the dictator requests, spell the names
of cities (which you may have never heard of) as well as local schools,
stores, etc. All of this may require an extensive amount of
research.
As well as all this, an MT is required
to know how to format this legal medical document correctly,
as per the doctor's, clinic's, or hospital's instructions.
You will have to use proper headings, subheadings, numbering, etc.
Years ago it just went along with other
clerical duties performed by secretaries in medical offices.
They were just expected to "do it" which, obviously, resulted
in a lot of angry, stressed out secretaries OR poor quality documents.
However, today there are many quality
education programs available to prospective MTs wanting to enter
the profession. In addition, many employers now require that
you have a formal MT education if you have little to no experience
in the field.
Finding a school to provide a good
foundation for starting a job as an entry level MT, as well as job
assistance, is the key. There are many companies who wouldn't normally
hire new graduates without experience, but are willing to test graduates
of a handful of quality educational programs. The first step
is to peruse such sites as MT
Chat, which has many articles on the subject as well as many
experienced MTs from whom you may learn a great deal about the profession.
Contact some national transcription companies and ask about the
schools from which they hire graduates. One school may be
better than another and you will have to do your own research and
pick the school that is right for your needs. Remember, you
get what you pay for.
Recently, the American Association
For Medical Transcription has begun a program for the purpose of
evaluating different MT schools against the association's criteria
of what is considered a quality MT education. Of note, the
school itself must submit an application for evaluation. This
is a brand new program which should prove to be an excellent aid
in helping guide prospective students. There are 10
schools that have been approved by AAMT.
Honestly, it depends on the MT.
If the MT needs to pay the bills, she will. If the MT wants
a part time job to add to the family income, then she can have that,
too. If the MT needs medical or dental benefits, there are
companies that provide that as well.
Your pay check depends of course on
your rate of pay, but also on the amount you produce. This
is a production job and you can crank out as much or as little work
as your little fingers can manage, as long as the work is there
to crank out of course.
I will, however, guarantee that you
will not get rich as an MT (unless you've got some great stock tips).
You may not even be able to pay the bills for the first year or
so. You will not even come close to learning everything you
need to know in school and it will take months to find your rhythm
and to stop having to research for half of your working day.
Typing speed really has little to do with this profession.
That being said, at some point you
may become accustomed to your accounts and dictators, build up a
significant number of normals, and generally become more experienced
in the art of transcribing with regard to knowledge of terminology,
account-specific formatting, etc. At some point, the amount
of time spent researching will diminish. The number of blanks
left will taper off. If you get to this point, and become
good at what you do, not only can you make a very decent paycheck
but you can have fun doing it as well!
First and foremost, medical transcription
is a profession. The documents that an MT produces are legal
medical documents that will be used to document patient care
for future follow-up appointments, insurance and Medicare reimbursement,
as well as court proceedings. This is not and will never be
something to which you can allot only part of your attention and
concentration. While you are working, what is coming from
your headphones and your fingertips should be the ONLY thing you
are focused on at the moment.
This is a true "telecommuting"
profession that requires specialized knowledge, schooling, attention
to detail, possibly working a required schedule with specific hours
(though not always), and constantly answering for the quality and
quantity of work you produce. Your initials will be on that
document. The client and your employer don't care if there
was a baby on your lap when you misspelled "pylorus" or
when you gave a patient 810 mg of aspirin. You have to answer
for that regardless of your family responsibilities.
That being said, you can work at home
and still be at home with your children. I would not advise
starting this profession with small children or babies, however,
unless you are certain that you will have time during the day to
work with absolutely no interruptions (possibly a couple of consecutive
hours or more for very part-time, a full eight consecutive hours
a day for full-time).
Because many people would pay a lot
of money to buy that kind of fantasy, even if their instincts tell
them something is fishy, and that is what these companies count
on.
SAMPLE TRANSCRIPTION
REPORTS-
-Appendectomy-
PREOPERATIVE DIAGNOSIS:
Acute ruptured appendicitis with diffuse septic peritonitis.
POSTOPERATIVE DIAGNOSIS:
Acute ruptured appendicitis with diffuse septic peritonitis.
PROCEDURE:
Laparoscopy appendectomy.
ANESTHESIA:
General.
JUSTIFICATION:
The patient is a XX-year-old female seen in the emergency room
with a three-day history of abdominal pain and vomiting. She initially
was evaluated in [NAME] Hospital where she was diagnosed as having
food poisoning and sent home. She was seen by her primary care physician
yesterday who made no recommendations in terms of a diagnosis or
treatment. She comes in to the emergency room today with severe,
diffuse abdominal pain, nausea and vomiting. Her white count is
20,000 which is an increase from the initial count that she had
in the other hospital of 16,000. The abdomen is diffusely tender
and rigid with guarding, rebound tenderness and Rovsing sign-positive.
The ultrasound is consistent with acute appendicitis. The patient
was diagnosed as having a ruptured acute appendicitis. She was advised
about all the possible complications associated with the condition
and the procedure. She understands that, despite the antibiotics
and the appendectomy, in the presence of rupture she will need IV
antibiotics in a prolonged fashion for 10-14 days. Despite that,
the formation of an abscess is not completely avoided. She knows
all the complications of septic peritonitis, which could be a severe
condition with morbidity and mortality. It might require re-operation
or some kind of invasive intervention. She also understands small
bowel obstruction, bleeding, abscess, hematoma, injury to organs
in the vicinity such as vessels, bowel and nerves can occur. In
that event, surgical repair will be necessary. Cecal fistula also
was discussed with the patient as a possible complication, as well
as extra-abdominal complications such as DVT, pulmonary embolism
and pneumonia. She also understands that conversion of the laparoscopic
procedure to open might be necessary.
PROCEDURE IN DETAIL:
Under general anesthesia with the patient in the supine position,
the abdomen was prepped and draped in the usual sterile fashion.
After a small incision was created in the umbilicus, we proceeded
to insert #5 ports in the right upper quadrant, as well as one suprapubically.
We inserted a #12 port in the umbilicus. Upon getting to the abdominal
cavity, we immediately found about 100 mL of thick, greenish fluid
that was aspirated with a long needle and sent to the lab for cultures
for aerobes and anaerobes. We then proceeded to do aspiration of
the fluid until it was dry. We then concentrated our attention on
the right lower quadrant. The appendix was undoubtedly inflamed.
It was in the pelvic position, traveling into the true pelvis, over
the rim, right next to the right ovary and tube. The appendix was
stuck to the lateral wall. It took some blunt dissection with some
bleeding in the area to dislodge the appendix. That also created
some bleeding from the right ovary. Once the appendix was brought
up into the true abdomen, we then proceeded to hold it in place,
open a window in the mesoappendix, and then fire a vascular GIA
to transect the pedicle and another one to transect the organ. This
was then retrieved with the use of an Endopouch. We then spent some
time irrigating all the debris, pus and blood from the whole abdominal
cavity with the use of aspiration and irrigation. We were then satisfied
that the cavity was completely dry. One point of bleeding on top
of the ovary was controlled with the use of an Endoloop. At the
end, we reviewed all the different compartments and irrigated extensively
until the water came back clear. I did not find any fluid collections
and was satisfied that there was no other pathology. The pneumoperitoneum
was reversed and the wounds closed in the usual fashion.
-Laryngoscopy-
PREOPERATIVE DIAGNOSIS:
1. Posterior commissure mucosal irregularity noted on video
stroboscopy.
2. History of significant GERD, failing maximal
PPI therapy.
POSTOPERATIVE DIAGNOSIS:
1. Posterior commissure mucosal irregularity noted on video stroboscopy.
2. History of significant GERD, failing maximal
PPI therapy.
PROCEDURE:
Microscopic diagnostic laryngoscopy with directed biopsy:
ANESTHESIA:
General endotracheal anesthesia.
INDICATIONS:
The patient is an XX-year-old white female with a history of
intermittent dysphonia and significant GERD. She was noted to have
mucosal irregularity on video stroboscopy in the posterior commissure
region, consistent with pachydermia. Given her significant GERD
history and her concerns of a possible early malignancy and dysplasia
(previous lung cancer patient), she is being taken to the OR for
a diagnostic microscopic laryngoscopy with directed biopsy of this
posterior commissure mucosal area.
FINDINGS:
1. Fairly normal-appearing mucosal exam on laryngoscopy as well
as diagnostic laryngoscopy.
2. Under high magnification and zero-degrees-toward-camera
photo documentation, there appears to be a slight mucosal irregularity
and discoloration consistent with the previously-mentioned pachydermia.
Biopsy of this area obtained, only of the mucosa.
PROCEDURE IN DETAIL:
The risks, benefits, and alternatives of the procedure were
discussed. Informed consent was obtained. The patient was taken
to the operating room and placed under general anesthesia. Once
the appropriate level of anesthesia was obtained, the patient was
turned over to the ENT service for completion of the surgical procedure.
The head of the bed was rotated 90 degrees to the right and the
patient had upper and lower tooth guards placed. Using a laryngoscope,
the oral cavity and oropharynx was inspected. There were no mucosal
irregularities, abnormalities, or lesions identified. Base-of-tongue
palpation and palpation of the right and left tonsillar fossa revealed
no induration, tumors, or masses. The neck was palpated and found
to be without evidence of adenopathy. The supraclavicular fossae
were found to be the same, without evidence of masses or lesions.
The larynx was photo-documented after the patient
was placed in Lewy suspension. No mucosal irregularities were noted
on the false vocal cords or true vocal cords bilaterally.
The patient was then taken out of suspension. The
endotracheal tube was placed anterior to the laryngoscope and pictures
of the cervical esophageal introitus, arytenoids, and posterior
commissure were taken. Under high magnification, there was a slight
mucosa irregularity noted without ulceration in the posterior commissure,
consistent with her previous video stroboscopic findings.
Although this was not definitive for a carcinoma,
given her significant reflux history and this abnormal-appearing
whitish plaque on high magnification, we decided to obtain a mucosal
biopsy of this lesion.
Using a microcup forceps, a mucosal biopsy of this
lesion was taken in the posterior commissure. A small area of mucosa
was also removed and cut with curved micro-scissors. This was placed
in formalin and sent for permanent section diagnosis. Hemostasis
was obtained with cocaine neuropledgets. Care was taken not to perform
a biopsy in two opposing areas on the posterior commissure to prevent
webbing. The patient tolerated the procedure well. There were no
complications. She was turned over to the anesthesia service who
awoke the patient without difficulty. She was extubated and transported
in stable condition to the recovery room where she remained until
she met discharge criteria. The patient tolerated the procedure
well with no complications.
SPECIMENS TO PATHOLOGY:
Posterior commissure mucosal irregularity: Rule out dysplasia
versus neoplasm.
POSTOPERATIVE INSTRUCTIONS:
1. Voice rest times five days.
2. Tylox 1-2 tabs p.o. every six hours p.r.n. pain.
3. Follow up with me in one week for discussion
of pathology results.
MT Associations
American
Association For Medical Transcription
Medical
Transcription Industry Association
National
Healthcareer Association
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