Intro To Medical Transcription


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Medical Transcription 101

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Intro To Medical Transcription

  1. 1. Introduction to Medical Transcription Joahnna Almero SE MT Instructor
  2. 2. What is Medical Transcription ? <ul><li>Medical Transcription ( MT ) is the process of converting voice dictation (typically either cassette or digital format) into a permanent written record utilizing word processing equipment and software. </li></ul><ul><li>Physicians and medical record handlers alike must be extremely careful to ensure that detailed patient identification information accompanies each procedure and examination report to avert potentially disastrous mix-ups. </li></ul><ul><li>Over time, all of this information accumulates in a centralized medical records repository where it serves as a critical resource for patient care - facilitating accurate diagnoses and appropriate treatments. </li></ul>
  3. 3. What is a Medical Transcriptionist? <ul><li>Medical transcriptionists ( MTs ) are specialists in medical language and healthcare documentation. </li></ul><ul><li>They interpret and transcribe dictation by physicians and other healthcare professionals regarding patient assessment, workup, therapeutic procedures, clinical course, diagnosis, prognosis, etc., editing dictated material for grammar and clarity as necessary and appropriate. </li></ul>
  4. 4. Profile of a Filipino MT <ul><li>Age : 62% in the bracket of 26-30 y/o , 20% in the below 25 y/o , </li></ul><ul><li>11% 31-35 y/o , </li></ul><ul><li>7% above 35 y/o . </li></ul><ul><li>Gender : more females at 78% </li></ul><ul><li>Educational background : </li></ul><ul><ul><li>medical 84%, nonmedical 16% </li></ul></ul><ul><li>MT training : in house 74%, </li></ul><ul><li>graduates of MT schools 27% </li></ul>
  5. 5. History & Evolution of Medical Transcription <ul><li>In the past, these records consisted of very abbreviated handwritten notes done by medical secretaries and assistants as dictated by the physicians. </li></ul><ul><li>Ultimately, handwritten notes and typed reports was consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department. </li></ul><ul><li>To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy. </li></ul>
  6. 6. <ul><li>In recent years things have changed considerably. </li></ul><ul><ul><li>1950s , manual typewriters </li></ul></ul><ul><ul><li>1960s , self-correcting electric typewriter </li></ul></ul><ul><ul><li>1970s , handheld microcassette dictation machine </li></ul></ul><ul><ul><li>1980s , electronic word processors and personal computers, sophisticated copying machines </li></ul></ul><ul><ul><li>1990s , digital dictation </li></ul></ul>History & Evolution of Medical Transcription
  7. 7. <ul><li>Filing cabinets have given way to desktop computers connected to powerful mainframe systems where patient records are prepared and archived digitally. </li></ul><ul><li>This digital format allows for immediate remote retrieval by any physician who is authorized to review the patient information. </li></ul><ul><li>Reports are stored electronically and printed selectively as the need arises. </li></ul>History & Evolution of Medical Transcription
  8. 8. <ul><li>While the transition from a paper based to an electronic format will take years to complete, considerable progress has been made. </li></ul><ul><li>Verbal dictation is now by far the most common method for documenting and reporting the results of examinations and procedures. </li></ul><ul><li>Dictating reports verbally not only allows physicians to be more thorough in their reporting, it also saves them a great deal of time. </li></ul><ul><li>Physicians generally use either a cassette based voice dictation system or a digital voice dictation system to record their findings. </li></ul>History & Evolution of Medical Transcription
  9. 9. HIPAA <ul><li>&quot; HIPAA &quot; is an acronym for the Health Insurance Portability & Accountability Act of 1996 </li></ul><ul><li>Also known as the Kennedy-Kassebaum Act </li></ul><ul><li>Requires: </li></ul><ul><ul><li>Improved efficiency in healthcare delivery by standardizing electronic data interchange , and </li></ul></ul><ul><ul><li>Protection of confidentiality and security of health data through setting and enforcing standards . </li></ul></ul>
  10. 10. HIPAA <ul><li>More specifically, HIPAA called upon the Department of Health and Human Services (HHS) ensures: </li></ul><ul><ul><li>Standardization of electronic patient health, administrative and financial data </li></ul></ul><ul><ul><li>Unique health identifiers for individuals, employers, health plans and health care providers </li></ul></ul><ul><ul><li>Security standards protecting the confidentiality and integrity of &quot;individually identifiable health information,&quot; past, present or future. </li></ul></ul><ul><ul><li>The bottom line: sweeping changes in most healthcare transaction and administrative information systems. </li></ul></ul><ul><li>Who is affected? Virtually all healthcare organizations. </li></ul>
  11. 11. Tools and Equipment <ul><li>Personal Computer </li></ul><ul><li>Headset </li></ul>
  12. 12. <ul><li>Foot Pedal </li></ul><ul><li>Keyboard </li></ul>Tools and Equipment
  13. 13. Tools and Equipment <ul><li>Transcription Software </li></ul><ul><li>Word Processor </li></ul>
  14. 14. Tools and Equipment <ul><li>Ergonomic Furniture </li></ul><ul><li>Modem and the Internet </li></ul>
  15. 15. Tools and Equipment <ul><li>Dictation Tools </li></ul><ul><li>References and Other Software </li></ul>
  16. 16. Qualities of an Ideal MT <ul><li>A well-trained MT Brain . (the most important). </li></ul><ul><li>Well-trained MT ear </li></ul><ul><li>Technology-savvy </li></ul><ul><li>English proficient, excellent proofreading skills </li></ul><ul><li>Fully oriented with the AAMT Book of Style </li></ul><ul><li>Familiar with MT productivity tools </li></ul><ul><li>Able to focus on work and ignore all distractions </li></ul><ul><li>Composed under pressure </li></ul><ul><li>Patient and very keen to details </li></ul><ul><li>Flexible </li></ul>
  17. 17. MT Skills Keyboarding Word Processing Referencing Basic Computing Anatomy & Physiology Pathophysiology Pharmacology Surgery Medical Terminologies Trends English Grammar Listening American Accent Proofreading & Editing Medical Terminologies
  18. 18. Trends in MT <ul><li>The Outsourcing Trend </li></ul><ul><li>In an effort to remain competitive, many hospitals have turned to outsourcing as a means of cutting costs. Many of the processes that were previously performed internally are now being contracted out to third parties. </li></ul><ul><li>This proliferation of outsourcing agreements has spawned a new generation of small medical transcription companies intent on carving out a piece of the pie. Interestingly, in spite of its rapid growth, the medical transcription industry is still considered a cottage industry. </li></ul>
  19. 19. Trends in MT <ul><li>Globalization of MT workforce </li></ul><ul><li>Changing nature of MT craft </li></ul><ul><li>Internet-based techniques reaching maturity </li></ul><ul><li>Regulatory processes </li></ul><ul><li>Upward pricing pressure based on global MT labor shortages </li></ul><ul><li>Speech Recognition technology </li></ul>
  20. 20. Ergonomics
  21. 21. Keyboarding <ul><li>Typing Master Pro 7.0 </li></ul><ul><li>Accuracy over Net Speed </li></ul><ul><li>MTs need to have at least 50 wpm with 100% accuracy to be very work-efficient. </li></ul><ul><li>Activity #1: Keyboarding: 5 mins. </li></ul>
  22. 22. Transcription Process <ul><li>Requires good foot-hand coordination , good hearing , application of all MT skills . </li></ul><ul><li>Express Scribe player, headset, PC, audio file, foot pedal. </li></ul><ul><li>Activity #2: Transcribe general dictation. </li></ul><ul><li>Activity #3: Transcribe actual doctor dictation. </li></ul>
  23. 23. Transcription Results <ul><li>Original transcripts for </li></ul><ul><ul><li>Simple transcription </li></ul></ul><ul><ul><li>Actual doctor dictation </li></ul></ul>
  24. 24. FAQs about MT <ul><li>Q. Where do medical transcriptionists work? </li></ul><ul><li>Medical transcriptionists work in hospitals , clinics , physician offices , transcription services , insurance companies , home healthcare agencies , and other locations where dictation for the purpose of healthcare documentation requires transcription. Many MTs work from their homes as independent contractors, subcontractors, or home-based employees. </li></ul>
  25. 25. FAQs about MT <ul><li>Q. Can I do medical transcription at home? </li></ul><ul><li>More and more employers are allowing their experienced MTs to work from home. However, many will require you to work at their facility or in their office before sending you home to work on your own. The home transcriptionist needs an excellent knowledge of the medical language , as well as the English language , and may have to make a substantial investment in reference materials and equipment. </li></ul>
  26. 26. FAQs about MT <ul><li>Q. How are medical transcriptionists paid? </li></ul><ul><li>Medical transcriptionists may be paid in any of a variety of ways, but chiefly by the hour , by production , or by a combination of hourly pay plus incentive pay for production. </li></ul><ul><li>Entry-level MT gets minimum wage. </li></ul><ul><ul><li><1 year or >6 months experience gets P9,000 a month. </li></ul></ul><ul><ul><li>>1 year experience gets P12,000 a month. </li></ul></ul>
  27. 27. <ul><li>End of Slide. </li></ul><ul><li>Thank you! </li></ul>