Everything You Need to Know About Medical Transcription

Earlier, we covered upper gastrointestinal transcription terms. Now, this week we will take a look at medical terminology for lower gastrointestinal problems.

 1) Appendicitis is inflammation of the appendix. It occurs most often between 11 and 30 years of age. Treatment of appendicitis is immediate surgical removal (appendectomy).

2) Peritonitis is the inflammation of the peritoneum. The basic treatment for acute peritonitis is a combination of surgery and antibiotics.

3) Gastroenteritis is the inflammation of the lining of the stomach and intestine.

4) Irritable bowel syndrome (IBS) is the most common disorder treated by a gastroenterologist that is not associated with any organic disease such as ulcers or tumors.

5) Ulcerative colitis is an inflammatory disease, with the formation of ulcers within the mucosa of the colon. It most often affects the rectosigmoid and left colon.

6) Crohn's disease, or inflammatory bowel disease. The cause of Crohn's disease is unknown. Crohn's disease is treated with antibiotics, steroids and diet.

7) Polyps. The most common types of polyps are hyperplastic and adenomatous polyps. With the use of colonoscopy and techniques such as hot biopsies and snares, polyps can be removed without major surgery before they become cancerous.

8) Diverticulosis is the presence of diverticula without inflammation. Diverticulitis is the inflammation of the diverticula, especially in the wall of the colon. This can have dire consequences of obstruction, bleeding, and perforation.

9) Hemorrhoids are varicose veins in the mucous membrane inside or just outside the rectum - internal and external hemorrhoids.

Gastroenterology is the study of the structure, function, disorders and diseases of the digestive organs. Constantly, new drugs and procedures make gastroenterology an exciting specialty in the medical transcription arena. Below are some terms you will hear physicians dictate during the course of a day's work.

 Upper Gastrointestinal Problems:

1)  Gastroesophageal Reflux Disease or more commonly known as GERD. This is not a disease but a syndrome produced by conditions that result in the reflux of gastric secretions into the esophagus. GERD usually presents as a discomfort in the lower chest and upper stomach. Treatment includes changing the patient's eating habits, avoiding irritants, and using antacids to neutralize acid that has been regurgitated into the esophagus.

2)  Hiatal Hernia occurs when a part of the stomach protrudes up into the chest through the diaphragm. Treatment includes dispensing antacids and antisecretory agents, elimination of tight garments, avoidance of liftiing, elimination of alcohol and smoking, and weight loss.

3)  Esophagitis is inflammation of the esophagus. May be caused by chemical irritants such as lye or dust or physical irritants such as smoking and excessive alchol use, trauma to the esophagus, and carcinoma.

4) Gastritis is inflmation of the linig of the stomach. Gastritis is one of the most common stomach disorders and occurs in acute, chronic and toxic forms.

5)  Peptic ulcers. An ulceration of the mucous membranes of the esophagus, stomach or duodenum. There are two types of peptic ulcers: gastric ulcers (occur in stomach) and duodenal ulcers (occur in the duodenum).

Thinking about going to the next level in your business - tired of picking up and delivering tapes.  In today's market, it is very easy to upgrade your medical transcription services to a digital dictation/transcription service.  The first thing you will need to do is find yourself a Transcription Application Service Provider (TASP).  The TASP is a third-party vendor who rents or sells application services for transcription workflow management.  These applications are typically web-based.

With the web-based application your TASP will be able to accept telephone dictation from any analog or digital phone line, as well as from hand-held recording devices. Some features to consider in your search for a TASP are: Make sure there is a secure electronic transfer of patient information that meets HIPAA requirements.  The technology needs to ensure private and secure transmission of data between the medical transcriptionist, hospital, clinic and/or office and the physician.  You want to have audit features that automatically records who has accessed a file and when.  You can track and audit the activity on each of your patient's files.  Additionally, you want to look for features that include archival services where you can retrieve and store your patient files securely, privately and confidentially online for easy 24/7 access. 

With the web-based application as soon as the digital dictation is complete and downloaded it goes to a secure server for transcription.  The medical transcriptionist has access to the dictation via the web.  Once the MT has transcribed the report the client also has access to that completed report via the web.  So, the question is will you get out of your comfort zone and take your business to the next level by going digital. 

Please feel free to leave comments. 

Certification is a process of regulation based on meeting select eligibility requirements to attain credentials, CMT, and maintain professional standards within the occupation.  An increasing number of state and government agencies are requiring certification.  A national certification can provide career advancement, job security and a higher paying job. 

The National Healthcareer Association (NHA), established in 1989 has become the largest organization with over 200,000 allied healthcare professionals certified.  NHA offer certification in three areas of study:  Clinical, Administrative and Instructional.  The certification for the medical transcriptionist falls in the Administrative category.

NHA certified individuals have demonstrated knowledge of their field, and stay current with advancements in the healthcare industry through their continuing education.  The certification exams are presented by more than 1300 training organizations, 600 online training institutions and 526 military testing sites (DANTES).

The criteria requirements to take the NHA National Certification Exam are:  You Must have either a High School Diploma, or equivalency; and you must have recently successfully completed an NHA-approved training program  OR  You Must have either a High School Diploma or equivalency and you must have recently worked in the field of certification (as a medical transcriptionist) for a minimum of 1 year. 

Candidates must be able to provide written proof of experience by Director or Employer.

Medical transcription is a fascinating and rewarding career for the individual with a quest for lifelong learning.  As the MT attain knowledge, experience and enhanced skills he or she is positioned to navigate the career pathway with myriad opportunities. 

Keep in mind as you start your MT journey most employers prefer medical transcriptionists who have completed a postsecondary training program at a vocational school or community college.  This is highly recommended, but not always required.

Many MTs telecommute from home-based offices as employees or subcontractors for hospitals and transcription services or as self-employed, independent contractors. 

MTs who work in physicians' offices and clinics may have other duties, such as receiving patients, scheduling appointments, answering the telephone, and handling incoming and outgoing mail. 

As a MT embrace professional development and grow in knowledge and expertise he or she can advance to supervisory positions, home-based work, editing, consulting, or teaching.  With additional education or training, some MTs become medical records and health information technicians, medical coders, or medical records and health information administrators. 

Medical transcriptionists can also work for business support services, for example transcribing legal depositions for lawyers.  In addition to working for hospitals, physicians and clinics MTs can work in offices of other health practitioners, medical and diagnostic laboratories, outpatient care centers, ambulatory surgery centers and home healthcare services. 

Job opportunities in the medical transcription arena are good.  According to documented research from the United States Department of Labor, medical transcription is expected to grow faster than the average for all occupations through 2016.  A high level of demand for transcription services will be sustained by the continued need for electronic documentation that can be easily shared among providers, third-party payers, regulators, and consumers. Additional medical transcriptionists will be needed to amend patients' records, edit for grammar and identify discrepancies in medical records.

Contracting out transcription work overseas and advancements in speech recognition technology are not expected to significantly reduce the need for well-trained MTs domestically.  The demand for overseas transcription services is expected to supplement the demand for well-trained domestic MTs. 

Speech-recognition technology allows physicians and other health professionals to dictate medical reports to a computer that immediately creates an electronic document.  In spite of the advances in this technology, it has been difficult for the software to grasp and analyze the human voice and the English language with all its diversity.  As a result, there will continue to be a need for skilled medical transcriptionists to identify and appropriately edit the inevitable errors created by speech recognition systems, and create a final document.  With speech recognition technology the medical transcriptionist can develop and cultivate an entirely new skill set as a speech recognition editor.

Hospitals will continue to employ a large percentage of medical transcriptionists, but job growth there will not be as fast as in other industries.  Increasing demand for standardized records should result in rapid employment growth in offices of physicians or other health practitioners, especially in large group practices.

Medical transcription is a language skill, not a keyboarding skill.  However, to get started in your professional career you need to be able to type at least 50 words per minute.  Not sure of your typing speed, you can pick up a Mavis Beacon Typing Tutorial from your local Office Depot.  The typing tutor has about 425 typing lessons, English/Spanish versions and you can track your progress.  In the past, I have recommended Mavis Beacon and prospective students have called me back with positive feedback on how much the tutor helped to increase typing speed. 

Next, at a minimum,  you need to take classes in Medical Terminology, Anatomy and Physiology, and a Medical Transcription Practice Lab comprised of authentic physician dictation.  It is important for the practice lab to have actual dictation recorded by practicing physicians after seeing a real patient (with the names changed).  Authentic dictation includes all the background noises, misspeaks, errors and more that MTs encounter every day on the job. Learning with "authentic physician dictation" is the only way to develop the auditory, interpretive, and decision-making skills necessary to become a successful MT.

To get started first thing - assess your typing/ keyboarding skills and then check out your local community college and/or on-line schools for classes in Medical Transcription Fundamentals.

So you are thinking about medical transcription as a profession. Take a look at the list of interests, abilities and attributes and ask yourself those questions.  If you can answer yes to a majority of the questions, now is the time to develop, cultivate and nurture your interests, abilities and attributes as you begin your academic and career  journey to becoming a professional medical transcriptionist.

Interests:  Are you interested in medicine?  Do you like to read?  Are you challenged by lifelong learning? Do you want to make a contribution to the health care arena? Do you like to type and use computers?

Abilities:  Can you type at least 50 words per minute? Do you have a mastery of Basic English language, punctuation, grammar and spelling? Do you have dictionary and reference book use skills?  Can you sit comfortably for an extended time? Do you have good hearing acuity and language discrimination skills?

Attributes:  Likes words and language usage; logical and organized; likes to work independently; cares about quality and excellence; is flexible and adaptable; willing to learn and take correction; curious with an affinity to detail; has decision-making and critical thinking skills.

The MT listens to dictated recordings by physicians and other health care professionals and transcribes the reports as permanent records of patient care documentation.  This function is carried out, primarily, on a computer with Internet connection, headset, and foot pedal. 

The MT transcribes the four major report types for acute care facilities/ hospitals which include History and Physical, Consultation, Operative Report and Discharge Summary.  Other areas of medical transcription include Emergency Medicine, Radiology/ Diagnostic Imaging Studies, Pathology and Autopsy.  Some MTs are also finding success transcribing veterinary medicine reports. 

To understand and accurately transcribe dictated reports the MT must excel in medical terminology, anatomy and physiology, and treatment assessments.  The MT must be able to translate medical language and abbreviations into an expanded form.  The MT develops effective research skills for printed and electronic reference materials.  Additionally, the MT complies with specific industry quality standards and guidelines that apply to confidentiality, privacy and security of medical records.

A high quality reference library is imperative for your success as a professional medical transcriptionist.  You want your library to be reflective of premier reference resources.   Building and maintaining your library plays a vital role in the continuous quality improvement process.

The reference library must haves include but are not limited to the following list: 

1) Current Editions of AAMT Book of Style, Medical Transcription Guide Do's and Don'ts, Vera Pyle's Current Medical Terminology,  American Drug Index and a Pharmacology Word Book.

2) Medical Dictionary - Stedman's or Dorland's.  The Dorland's Dictionary includes a free downloadable electronic spell-checker software.  It is easy to install and enables computer to recognize over 100,000 medical terms.  Dorland's also has a Word of the Day feature where you receive a new word and its official definition 365 days a year.

3) English Dictionary - Microsoft Encarta Concise English Dictionary is an excellent reference tool.

4) Latest editions of specialties, for example Stedman's Medical & Surgical Equipment Words, Stedman's Cardiology & Pulmonary Words, Stedman's OB-GYN Words, Stedman's Orthopaedic & Rehab Words, and Stedman's Radiology & Oncology Words.

Please feel free to post comments.

To get started working at home as a medical transcriptionist you want to set your office up away from distractions, i.e. TV, family entertainment area.  You want to have a designated office space for privacy and security reasons. 

Your home computer requirements for hardware are atleast 512 MB of RAM, Intel Pentium II processor with at least 397 MHz and  Windows XP-Professional.  Many of the transcription platforms are not supported by Windows Vista.

For software, you want to have atleast 2003 Version of MS Word, Power Point and Excel.  You need a Virus software (i.e. Norton), Firewall, Medical Spellchecker (Stedman's) and Internet Explorer 7. 

You will also need a WAV footpedal, which you can insert into the USB port,  and a headset.