Introduction to Medical Introduction to Medical TranscriptionTranscription

Margaret F. BelloMargaret F. Bello

LecturerLecturer

Medical Transcription: OverviewMedical Transcription: Overview

Medical Transcription (MT) is the act of translating from oral to written form (on paper or electronically) the record of a person's medical history, diagnosis, prognosis, and outcome in order to document patient care and facilitate healthcare services. These documents eventually become part of patients’ permanent files.

Purposes of MTPurposes of MT

Ancient cave writings attest to the earliest forms of healthcare documentation. While the medium changed from metal plates to clay tablets, to hieroglyphs on temple walls, to papyrus, to parchment, to paper, and most recently to electronic files, the reasons for maintaining records have always been the same—to record an individual's health care and the achievements in medical science.

Verbal dictation is by far the most common method for documenting and reporting the results of examinations and procedures. Physicians generally use either a cassette based voice dictation system or a digital voice dictation system to record their findings. Dictating reports verbally not only allows physicians to be more thorough in their reporting, it also saves them a great deal of time.

Brief History: Brief History:

Since 1978, medical transcriptionists have been represented by a professional organization, the Association for Healthcare Documentation Integrity (AHDI), which has developed a competency profile (COMPRO®) and a model curriculum for transcription educators, as well as a model job description. AHDI emphasizes continuing education for its members, holding an annual conference for medical transcriptionists, educators, supervisors and managers, and business owners. There are over 135 component associations of AHDI, each of which holds regular educational meetings and symposia.

Through the efforts of AHDI, medical transcriptionists have become recognized as healthcare professionals with expertise in medical language.

To prepare for this profession, To prepare for this profession, medical transcriptionists studymedical transcriptionists study

medical language, including Greek and Latin suffixes, prefixes, and roots biological science, including anatomy and physiology of all body systems and various disease processes

medical science medical and surgical procedures, involving

thousands of instruments, supplies, appliances, and prosthetic devices

pharmacology laboratory values, correlating laboratory test results

with a patient's diagnosis and treatment use of medical reference materials and research

techniques

MEDICAL TRANSCRIPTION MEDICAL TRANSCRIPTION OPERATIONSOPERATIONS

WORK FLOW DIAGRAMWORK FLOW DIAGRAM

Background of MT in the Background of MT in the PhilippinesPhilippines

Total MT Firms: 30 Total MT Firms that are MTIAPI: 27 Total MT Schools: 9 MT Professionals: 3,000 employed Performance Level: 98 – 99% accuracy rate, turnaround time of 12 to 24 hours

What drives the demand for MT?What drives the demand for MT?

Demographic data indicates that our Demographic data indicates that our population is rapidly aging at the population is rapidly aging at the same time we are achieving same time we are achieving significant improvements in average significant improvements in average lifespan. These demographic lifespan. These demographic patterns along with technological and patterns along with technological and legal trends suggest that the need legal trends suggest that the need for accurate medical transcription will for accurate medical transcription will accelerate dramatically in coming accelerate dramatically in coming years. years.

Salary expectationsSalary expectations

Annual income for full-time entry-level transcriptionists typing hospital reports averages between $20,000 - $35,000 - depending on location and proficiency.

More experienced transcriptionists can expect to make double or even triple that amount on the basis of production - particularly if they are willing to develop their own customer base. Unfortunately, the pay differential between experienced and non-experienced transcriptionists is not typically as large in hospital settings where transcriptionists are often paid by the hour. This is one of the primary reasons that experienced transcriptionists tend to seek out positions as independent or sub-contractors where the opportunity exists to leverage their earnings potential.

The BillingThe Billing It turns out that there is a fair degree of flexibility in It turns out that there is a fair degree of flexibility in

establishing billing parameters. It boils down to establishing billing parameters. It boils down to negotiating a rate with a prospective client. Even if negotiating a rate with a prospective client. Even if you determine that you will attempt to adhere to the you determine that you will attempt to adhere to the standards provided in the definitions above there is standards provided in the definitions above there is still a fair amount of lattitude that derives from the still a fair amount of lattitude that derives from the subjectivity inherent in the definitions. For example, subjectivity inherent in the definitions. For example, assume that you decide to bill based on a 65 assume that you decide to bill based on a 65 character line. character line.

For example:For example: Assume that for the billing period, your line count Assume that for the billing period, your line count

software calculates a total of 3,500,000 transcribed software calculates a total of 3,500,000 transcribed gross characters and that your contract defines a gross characters and that your contract defines a billable line as 65 gross characters. Assume that you billable line as 65 gross characters. Assume that you have negotiated a price of 14 cents per billable line. have negotiated a price of 14 cents per billable line. Your bill would be calculated as follows:Your bill would be calculated as follows:

3,500,000 divided by 65 = 53,846 billable lines3,500,000 divided by 65 = 53,846 billable lines 53,846 multiplied by .14 = $7,538.0053,846 multiplied by .14 = $7,538.00

Medical Transcription: HR Medical Transcription: HR ProfileProfile

High School Diploma Above-average knowledge of English

punctuation and grammar Excellent auditory skills Advanced proofreading and editing

skills Versatility in use of transcription

equipment and computers High degree of trainability Customer service orientation

Medical Transcription: Medical Transcription: HR ChallengesHR Challenges

Availability of trained manpowerAvailability of trained manpower Medical professionals seeking job Medical professionals seeking job

opportunities in other countriesopportunities in other countries Training institutions offering Training institutions offering

medical transcription coursesmedical transcription courses Length of MT training before Length of MT training before

becoming productivebecoming productive

Medical Transcription: Medical Transcription: ProgramsPrograms

Organization: Medical Transcription Industry Association of the Philippines Inc. (MTIAPI)

Establishes Policies / Regulations to MT standards

Key terms: Key terms:

Turnaround time - time need to Turnaround time - time need to prepare a document for prepare a document for submissionsubmission

Accuracy – Exactness. The Accuracy – Exactness. The ability of a measurement to ability of a measurement to match the actual value of the match the actual value of the quantity being. quantity being.

How are Medical Terms How are Medical Terms Constructed? Constructed? Most medical terms consist of one or more parts. These

word parts may include one or more of the following: Root Words Prefixes Suffixes Combining Vowels To help you better understand how this works, let's look at

an example. Consider the word cholecystectomy. At first glance, this

word seems quite complex. Cholecystectomy, which means excision (removal) of the gall bladder, is really a combination of four different word parts. Let's break it down into its sub parts and see if we can figure out why it means what it means.

chol - e - cyst - ectomy

MT SPECIALITIESMT SPECIALITIESMT SPECIALITIESMT SPECIALITIES

Immunology

Speech Pathology

ENT - Plastic Surgery

Neurology

Geriatrics

Podiatrics

Pediatrics

Addictive Disorder Treatment

Centers

Biochemical Genetics

Epilepsy Centers

Rehabilitation, etc.

General Medicine

Dermatology

Cardiology

Urology/Nephrology

Orthopedics

OB-GYN

GI/GU

Psychiatry

Ophthalmology

Pulmonology

Endocrinology

Hematology &

Oncology

REPORT TYPESREPORT TYPESREPORT TYPESREPORT TYPES

Discharge Summaries

Consultation

SOAP Notes

Operative Notes

Study reports (MRI/SCAN)

Urgent Care

Chart Notes

Worker Compensation Reports.

Example of a SOAP noteExample of a SOAP note

Patient Name: Robert Kryle DOB: 12/31/1961 Record No. K-6112r809Date: 09/09/99

S—Pt. states that she has always been overweight. She is very frustrated with trying to diet. Her 20 year class reunion is next year and she would likt to begin working toward a weight loss goal that is realistic. NKDA, NKA.

O—WT = 210 lbs HT = 60 “ BW = 115 lbs Chol = 255 BP = 120/75

A—Obese at 183% IBW, hypercholesterolemia

P—Long Term Goal: Change lifestyle habits to lose at least 70 pounds over a 12 month period. Short Term Goal: Client to begin a 1500 Calorie diet with walking 20 minutes per day. Instructed Pt on lower fat food choices and smaller food portions. Client will keep a daily food and mood record to review next session. Follow-up in one week.

———————————————————————————- Bob Ridman, CCMA   M. Myer, MD

END!END!