Medical records document all aspects of a person's medical care, including their symptoms, health history, the results of their healthcare providers’ 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 coverage or even lead to mistakes in treatment and care. Caregivers have a legal obligation to maintain accurate and up-to-date records on all patients.
Medical transcriptionists work with healthcare 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 that may be needed.
Medical transcriptionists listen to providers' dictated notes and translate them into a clear, organized record of the 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, nurse practitioners, and other healthcare providers dictate their confidential notes about each visit. Transcriptionists take these notes and transcribe them into a comprehensive record of the visit.
They use a 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 sure 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.
Education and Training
Most medical transcriptionists complete a certificate program that includes courses in medical terminology, anatomy, physiology, medical specialties, diagnostic studies, and pharmacology.
Some complete an associate's degree program. Medical transcriptionists are sometimes called medical language specialists, and they need to have an excellent command of grammar and punctuation.
They also have to be able to understand complicated medical terminology as well as medical and surgical procedures. In addition, they need to have good auditory processing skills and be able to understand accents.
The Association for Healthcare Documentation Integrity is the professional organization for medical transcriptionists. Medical transcriptionists are eligible for one of two certifications, depending on experience.
New transcriptionists, once they have graduated from a medical transcription program, can sit for the exam to become a Registered Healthcare Documentation Specialist (RHDS). The exam is open to transcriptionists with less than two years of experience or transcriptionists who work in only one specialty.
Once they have the RHDS certification, medical transcriptionists are eligible to become a Certified Healthcare Documentation Specialist (CHDS). To obtain their CHDS certification, transcriptionists must have at least two years of experience in an acute-care or multi-specialty clinic setting.
They also have to have obtained their RHDS certification. To keep their certification, RHDS transcriptionists must complete 20 hours of continuing education every three years or retake the exam. To keep the CHDS certification, transcriptionists must complete 30 hours of continuing education every three years.
Reasons to See a Medical Transcriptionist
Medical transcriptionists work behind the scenes with your healthcare provider to make sure your health history is correctly documented and transferred to other providers as needed. You will probably never see them in the ordinary course of your treatment.
However, you can see their work by requesting your medical records. It's a good idea to check your medical records to ensure their accuracy.
The Health Insurance Portability and Accountability Act (HIPAA) gives you the right to see and get copies of your health information, with a few exceptions. Many providers offer online access to your electronic medical record (EMR) through their websites.
If they don't, you are still entitled to access your records, keep them private, and request a change if you feel there is an error.