Introduction to medical transcription


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  • Consider that each day in hospitals all over the country, thousands of patients are admitted and discharged. Examinations are conducted, procedures are performed and recommendations are made. It is not uncommon for multiple physicians to be involved in a simple procedure for a single patient. Radiologists, Pathologists, Anesthesiologists, Surgeons, and a host of other medical specialists must all coordinate their efforts to ensure that patient care is both adequate and appropriate. Underpinning all of these activities is a complex web of medical and patient information. Each patient-related activity and procedure must be meticulously documented and then added to the patient's permanent record. 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. Indeed, timely patient care often hinges on the ability of Radiology, Pathology, and other specialty departments to quickly conduct their examinations and report their findings.
  • Rates as low as 6.0 to 8.0 Cents per line. Can be negotiable depending on the quantity.
  • Introduction to medical transcription

    1. 1. Introduction to MedicalIntroduction to Medical TranscriptionTranscription Margaret F. BelloMargaret F. Bello LecturerLecturer
    2. 2. 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.
    3. 3. 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.
    4. 4. 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.
    5. 5. 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
    7. 7. Background of MT in theBackground 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
    8. 8. What drives the demand for MT?What drives the demand for MT?  Demographic data indicates that ourDemographic data indicates that our population is rapidly aging at thepopulation is rapidly aging at the same time we are achievingsame time we are achieving significant improvements in averagesignificant improvements in average lifespan. These demographiclifespan. These demographic patterns along with technological andpatterns along with technological and legal trends suggest that the needlegal trends suggest that the need for accurate medical transcription willfor accurate medical transcription will accelerate dramatically in comingaccelerate dramatically in coming years.years.
    9. 9. 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.
    10. 10. The BillingThe Billing  It turns out that there is a fair degree of flexibility inIt turns out that there is a fair degree of flexibility in establishing billing parameters. It boils down toestablishing billing parameters. It boils down to negotiating a rate with a prospective client. Even ifnegotiating a rate with a prospective client. Even if you determine that you will attempt to adhere to theyou determine that you will attempt to adhere to the standards provided in the definitions above there isstandards provided in the definitions above there is still a fair amount of lattitude that derives from thestill 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 65assume 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 countAssume that for the billing period, your line count software calculates a total of 3,500,000 transcribedsoftware calculates a total of 3,500,000 transcribed gross characters and that your contract defines agross characters and that your contract defines a billable line as 65 gross characters. Assume that youbillable 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
    11. 11. Medical Transcription: HRMedical 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
    12. 12. Medical Transcription:Medical Transcription: HR ChallengesHR Challenges  Availability of trained manpowerAvailability of trained manpower  Medical professionals seeking jobMedical professionals seeking job opportunities in other countriesopportunities in other countries  Training institutions offeringTraining institutions offering medical transcription coursesmedical transcription courses  Length of MT training beforeLength of MT training before becoming productivebecoming productive
    13. 13. Medical Transcription:Medical Transcription: ProgramsPrograms Organization: Medical Transcription Industry Association of the Philippines Inc. (MTIAPI)  Establishes Policies / Regulations to MT standards
    14. 14. Key terms:Key terms:  Turnaround time - time need toTurnaround time - time need to prepare a document forprepare a document for submissionsubmission  Accuracy – Exactness. TheAccuracy – Exactness. The ability of a measurement toability of a measurement to match the actual value of thematch the actual value of the quantity being.quantity being.
    15. 15. How are Medical TermsHow 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
    16. 16. MT 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
    17. 17. REPORT TYPESREPORT TYPES  Discharge Summaries  Consultation  SOAP Notes  Operative Notes  Study reports (MRI/SCAN)  Urgent Care  Chart Notes  Worker Compensation Reports.
    18. 18. Example of a SOAP noteExample of a SOAP note Patient Name: Robert Kryle DOB: 12/31/1961 Record No. K-6112r809 Date: 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
    19. 19. END!END!