What does a Medical Transcriptionist do? I am a Hospital Medical Transcriptionist (MT). I transcribe hospital medical records for a living. For the patient who does not understand what a Hospital Medical Transcriptionist does, here is a scenario: Each time you go to the hospital, you are assigned a case number or medical record number. Each visit you make generates a sequence of medical reports about you and your illness, assigned to that medical record number. Let's say, for instance, you are having chest pains and present to your local hospital emergency room. You are carefully attended by a staff of nursing and other health care personnel and the emergency room physician. Just that hour or two (sometimes more) that you spend lying on the hospital cart will generate a flood of paperwork about you and your chest pains. With government regulations, utilization review boards, peer review boards, malpractice litigation, health insurance requirements, and the like, everything about your hospital stay will be documented. The emergency room physician will dictate a report about you and your chest pains into a dictation machine (or tank) and the Medical Transcriptionist is on the other end of that tape or machine, typing everything the doctor is saying about you and your case. As hospital Medical Transcriptionists, we must know how to spell the doctors' names correctly, medications and dosages, diagnostic studies and tests performed on you, the equipment that is being used, and most importantly, we must know all the different parts of your body, their functions, how to spell the names of those body parts, and all variety of diseases and disorders. We must know things like the difference between "dysphagia" and "dysphasia," and "peritoneum" and "perineum" even though words may sound alike to the untrained ear. And we must know things like "disc" is found in your eye, but "disk" is in your back! A "loupe" is used in your eye surgery, but a "loop" can be found in your colon. And much more! :)
Now, back to your emergency room visit: The doctor will dictate an Emergency Room
Your family doctor then admits you to the hospital. Each and every time you are admitted as an inpatient to the hospital, someone (usually your admitting physician) must dictate a report on you called a History and Physical. Covered in this report are things like the reason you are being admitted, your past medical history, medications you are on, your family medical history, your surgical history, a physical examination on you at the present time, and admission diagnosis and admission plans.
Your doctor then decides to call in a consulting physician, a cardiologist, because you have the chest pains and there is something wrong with your heart according to the tests that have been done. So, a cardiologist comes in to see you and after you are seen, he must dictate a Consultation Report which includes his findings and usually a physical examination and what his recommendations or plans are for your case. That generates a hard copy of another report in your ongoing medical record. Then, he decides you should have a cardiac catheterization and schedules you for that. At the conclusion of this procedure, he reviews the films taken during the catheterization, and must dictate a Cardiac Catheterization Report.
Perhaps it is decided you must have bypass surgery on your heart, due to blocked coronary vessels. A cardiovascular surgeon will be called in on the case and he will dictate another Consultation Report on you before you go to surgery.
So, you end up going to have open heart surgery. Usually before they have you awakened from your anesthesia, the surgeon or surgical resident will have already dictated your Operative Report, which gives a detailed blow-by-blow account of what happened when you were asleep under the "knife."
(A Medical Transcriptionist must know all of the terminology, operative procedures, surgical equipment and supplies, how everything is spelled, and have a working knowledge of the surgical procedures themselves, in order to transcribe what the surgeon is saying.)
We presume your surgery went fine and you spend the next several days in the hospital. You may have several more Consultation Reports dictated about you and if you develop any postoperative problems, you will likely have other reports dictated about you. You may have some cardiac rehabilitation and be discharged to what is called a "step-down" unit. You will be instructed on diet, activity, and postoperative care. Then, when you are ready to be discharged to go home, the final report about your hospital stay is called a Discharge Summary. This required report gives a general overview of why you were hospitalized, what happened to you during your hospital stay, what medications you are being discharged with, discharge plans, and followup plans. Your typewritten medical reports for this one particular hospital stay are now complete. Should you ever be hospitalized again in the future, your old medical records can be "called up" and reviewed at your next visit.
Somebody had to transcribe or type all that was dictated about you, and that somebody is a hospital Medical Transcriptionist.
I am a Hospital Medical Transcriptionist and I love my job! There are thousands of Medical Transcriptionists out here behind the scenes. We are an invisible, yet we are an integral and necessary part of your total health care team. We are the unseen force behind your medical documentation and proud of our profession. And some of us even pray for you while we type your reports! :)
If you visit some of the Report Links, you will find actual Hospital Reports (including Operative Reports) for real anonymous patients that were dictated by actual physicians. For confidentiality purposes, no real patient names, places or physician names are used. Newbie MTs or anyone thinking about going into Medical Transcription may find these sample reports useful, so feel free to print them. I will be adding more, so check back soon!
"Patients and Medical Transcription" at http://www.mt-stuff.com
If you do use these sample reports for students or classes, please let me know. My goal for this web site is to mentor future MTs to carry on our professional craft and legacy; I would like to know I helped in some small way to achieve that goal. Thank you and May God Bless You, Rosemarie
