Top Best Medical Transcription Course Institutes in Calicut

  Medical Transcription

Medical records document all aspects of a person's medical care, including their symptoms, health history, the result of their healthcare provider's exams, their diagnostic tests, as well as their treatment plan. They are vital for continuity of care and communication among healthcare providers.

Errors in medical records can affect insurance overage or even lead to mistakes in treatment and care. Caregivers have a legal obligation to maintain accurate and up-yo-date records on all patients.

Medical transcriptionists work work with health care providers to make sure that each visit is documented so that there is a complete record of the diagnosis and treatment plan as well as any follow up care may be needed.

Medical transcriptionists listen to providers' dictated notes and translate them into a clear, organized record of visit. They ensure that all aspects of a person's history, diagnoses, and treatment, are recorded. Then they use the facility's documentation system to file the medical records to be accessed at the next visit or sent to another facility if necessary.

What does a medical Transcriptionist do?  

 Doctors, nurses practitioners, and other healthcare providers dictate their confidential notes about each visit. Transcriptionist take these notes and transcribe them into a comprehensive record of their visit. They use template based on the type of practice, with most specialties having different requirements. Sometimes they receive files that are unedited speech-to-text

translations. They then edit and format these notes and turn them into a finished document. 

While they are transcribing, medical transcriptionists use their extensive medical terminology knowledge and critical thinking skills to make mistakes are minimized. If they encounter conflicting information, such as a person listed as taking a medication that they are allergic to, they stop and get clarification to make sure the record is accurate.

There are basic qualities and skills that a medical transcriptionist requires. Following are few of the skills needed:-

1. Typing speed : It is important in the productivity of a transcriptionist. techniques for building speed and efficiency on the keyboard is an invaluable tool for improving typing speed and thereby productivity. Usually  the industry requirements is 60-80 wpm.
2. Language and Grammar style : The ability to correctly structure and punctuate proper English sentences is vital in producing quality Medical Transcription reports. Hence, transcriptionists need  to have a thorough idea on when and how to use commas, semi colons, hyphenation, capitalization, subject- verb agreement and more.
3. Medical terminology : Understanding the language of medicine is essentially the most important and vital aspect of this career. Hence a constant improvisation on adding medical vocabulary is a must for a successful medical transcriptionist.
4. Human anatomy, Physiology and disease processes :  A general understanding of the human body and how it works is essential to medical transcription. Though not a thorough but a basic idea of all major body systems like musculo-skeletal system, cardio vascular system, endocrine system, reproductive system, digestive system, respiratory system, the brain and central nervous system and the sense organs including their functions , organs , common, diseases is required . These enable medical transcriptionist's to formulate an understanding of the terms they will hear based on logic
5. Good listening skill : MT's must be good at listening. The listening Skill is a must for correct transcription.
6. Research skills : A medical transcriptionist  must have excellent research skills. Physicians will abbreviate words and phrases and you must know where to look for the meanings of the abbreviations.

Ethical and Legal responsibilities

When dealing with confidential medical information, one must adhere to the highest ethical and privacy standards. Medical transcriptionist deal with confidential information everyday in the performance of their job, transcribing a physicians spoken dictation into typed, easy to read notes. This means that medical transcriptionists must have a clear understanding of the legal and ethical issues that affect them.

1. He should be aware of HIPAA laws that affect them .HIPAA , the acronym for the Health Insurance Portability and Accountability Act of 1996, set down rules that must be followed when dealing with confidential medical information.
2.  It also regulates the ways in which confidential medical information can be shared and who may have the access to the information.
3. If confidential, individually identifiable medical information is released improperly the result could include fines, the loss of the violator's medical license jail time or civil suits.   

    Therefore it is important that medical transcriptionist's treat the information they work with a secret and protect it from any unauthorized people. MT's should regard themselves as patient advocates. By careful and meticulous transcribing, MT's help to reduce medical errors and misdiagnosis. Quality medical Transcriptionists help the patient to get best medical care possible. It is MT's duty to clarify any unclear term or unfamiliar medical diagnosis before transcribing it. This can be done by consulting the library of medical reference materials, discussing the questionable term with more experienced medical transcriptionist or requesting the clarification from the physician or a person dictating the note in question.

 Accurate and timely transcriptions will ensure that the patient’s chart is up to date and correct which ensures the best possible medical care for each  patient. This way should an emergency arise all the patient’s most current medical information is present in the chart and is accurate and legible. When an ethical dilemma arises the Medical Transcriptionist (MT)  has the duty to seek such clarification. First of all discussing the situation with a supervisor or a mentor is one way to gain clarity regarding the situation and help Medical Transcriptionist decide what their next step must be, if it doesn’t work, the MT can go to a professional organization such as American Association of Medical Transcriptionist’s. It is the MT’s responsibility to make sure that the ethical dilemma is resolved in the best way for all involved especially the patient.