What is medical transcription?

The process of transcribing doctor-dictated dictations for the purposes of documentation as a medical record is simply termed as medical transcription. The person who transcribes the dictations into a document is a medical transcriptionist or a medical transcription professional. The process originated in the West. The person who did this job used to be called as a medical assistant who used to be with the doctor at the hospital writing down notes instructed by him. Advancement of this process is electronic conversion of the dictations.

Why and who?

For insurance purposes and maintenance of medical records. The major player outsourcing medical transcription work is USA. Canada, UK, and Australia have some. The outsourced countries include India, Philippines, Indonesia to name a few among others. The medical transcription professional needs a wide knowledge of medical terminology, American English, and critical thinking skills that may help him/her to interpret what is dictated to produce accurate documents. The dictator speaks over a hand-held device called a Dictaphone or a electronic recorder or a device which has a 1-button solution to upload his voice into the server. The transcriber downloads them at his location through a server that is provided to him by the organization he works for. He then transcribes the dictations into medico legal document.

Why outsourcing?

Medical transcription happens to be one of the earliest BPO jobs outsourced to India. Indians have strong English communicating skills due to the curriculum followed from the days pre-independence. The time difference of 12 hours between India and USA makes it easier for the doctors/clinics to have their reports on their table at their next visit to the clinic. Furthermore, cost of labor is much cheaper for the outsourcer.

Potential?

Medical transcription has a strong employment in both India and the United States. One can work for a company that serves for the Healthcare Industry. The model also involves working at home as independent contractors. In India, the independent home transcriptionist model is growing to gain much popularity. It is said, still a larger portion of the work is still to be outsourced from US. Both NASSCOM in India and the US Department of Labor have identified this career as having a higher growth potential year by year.

Earnings potential?

As far as the money making is concerned, the fresher in medical transcription earns a starting salary approximately around Rs. 5000 and after 2 years of experience, his money making capability goes to around Rs. 15,000. Careers advancement can lead him to become an Editor or a Leader of a team in a company which could fetch him around Rs.20,000 or more. In these days of growing population and a means to earn money, this is quite decent for an Indian standard.

Today when it comes to training as a medical transcriptionist you have a couple of choices you can either go to your local college or university or you can join one of the many online medical transcription schools instead. Certainly there are many advantages to be had from using such a school rather than doing your training in the more traditional way.

Not only are these courses generally cheaper to pay for, but also they provide you with the flexibility for you to be able to carry out your studies at a time to suit you. Certainly this is a great way for many stay at home mums to earn a career and start bringing additional money into the home.

If you do choose to make the move to become a medical transcriptionist and considering using an online school then there are certain things that you should be looking for in them. Below we take a look at just what some of the things that a good online school will offer in relation to the course you wish to take.

1. You should teach you about the medical terminology by teaching you the medical root words along with their various prefixes and suffixes which are used by medical professionals.

2. Through the course you will learn about the various parts of the human body and its various systems which make it function in the way that it does. You will learn through this course about the muscles and skeleton, the circulatory and respiratory systems. You will also learn about the digestive, nervous, lymphatic, endocrine, genitourinary and integumentary systems as well.

3. The course should teach you about human anatomy and physiology as well as about the various different human diseases. Also the course will teach you the various medical abbreviations that are used along with details of the various different diagnostic tests and procedures that are used by medical professionals. Plus you will learn to understand what pharmacology is.

4. During the time you study with your online medical transcription school you will be taught the correct layout of all documents that you will be transcribing in the future. Plus the kind of language and words that you will be required to use in order to produce the right kind of reports or medical letters.

Another important thing to look for if considering using one of the many online medical transcription schools to do your training through is find ones which offer you the chance of getting some work experience. Therefore look for those courses which include work placement schemes and will help you to find employment upon completion of the course and after you have received your qualification.

Qualifications

In order to be able to do an efficient job as a medical transcriptionist, you need to receive conventional training so that you gain a better understanding of the medical procedures and terms. During the course of your job, you will have to deal with and comprehend different aspects of medical science like anatomy, diagnostics, treatments and the like.

Various institutes and schools offer numerous online degrees and educational training programs. Some of them even provide assistance in job placement. However, to do your job satisfactorily, you should acquire practical work experience and knowledge. Besides this, the task of transcribing will become easier if you have other skills in basic computing, good listening, typing speed and command over the language.

Requirements

Although the job offers a good salary, it requires quite a good deal of interpretation and translation of medical terminology. As a medical transcriptionist you need to listen patiently to the recorded observations and factual descriptions so that you can convert it into a written document. You may also need to check the medical report for grammatical errors.

Purpose Of Medical Transcriptions

People like doctors working in the profession of medical science usually record facts and observations of their patients for future reference. A medical transcriptionist evaluates these recordings and makes a transliteration of the patient’s history, discharge reports and a summary of other physical examinations. This medical evidence is then reassessed by the health care professional. These transcribed scripts are collected and kept as records of the patient’s medical history for future reference or for insurance purposes.

Benefits Of Doing Medical Transcription From Home

Pursuing a career as a medical transcriptionist facilitates a broad spectrum of advantages. The job not only guarantees good income, but also offers you the advantage of working from the comfort of your home at your convenience. You have the flexibility of doing the job according to your work schedule.

However, you will have to install some necessary tools and equipment, such as computers, printers and transcribers. Medical books for reference and a word expander utility will prove to very helpful for the job. Also be careful that you do not fall a prey to any of the scam companies, which is true for any work at home job opportunity.

Job Opportunities

Due to the ever-increasing number of healthcare facilities, the need for maintaining records, and consequently the demand for medical transcriptionists, is also growing. Your career as a medical transcriptionist will require you to work in coordination with professionals employed in hospitals, healthcare centers, laboratories, and other medical centers. You also have the option of choosing to work individually from home, on a contractual basis. A transcriptionist with adequate practical education and information can be promoted to other senior positions of teaching and consulting.

Although the job of transcribing and meeting deadlines can be very tedious at times, high pay and other perks associated with the profession make the career very appealing and rewarding.

A midlife career change fills a basic need to which most of us can relate: the need for autonomy, independence, challenge, self-direction, making a difference professionally, improving the quality of our lives personally and professionally, and spending more time with our families.

As we grow in life, so too do our needs. The yearning for more control over our time and the need to carve out our destiny reaches its peak in midlife. When a midlife career change beckons, we have spent usually a couple of decades working for several bosses and start to realize there has to be something better out there. Personally, we know who we are. Financially, we may be at a point where we want to spend the rest of our working years doing what we love and knowing that we have made a difference in the world. In short, we want to leave a legacy behind as well.

When I was in my late 30s, I was a word processor but felt I needed more fulfilling and challenging work. I loved the medical field, so I decided to embark on a medical transcription midlife career change. It was thrilling and stimulating to meet new people in the medical transcription field and go after a career I thought might be out of my reach. I pursued this field with a passion I did not know I possessed. It was rejuvenating and has kept me feeling young and vital. I was/am a very successful medical transcriptionist because I love the work, am passionate about serving the patients whose medical reports I type, and take great pride in my accomplishments.

Prior to pursuing medical transcription, I assessed my personal strengths and weaknesses. In my case, I love computers, medical terminology, and writing. I have a great command of the English language and communicate very effectively with it. Consequently, I checked out legal and medical transcription, which were natural fits. When I looked into legal transcription, even though it paid pretty well, I knew it would bore me to tears. Therefore, I pursued medical transcription and found my true professional niche.

If you are unhappy, bored, burned out, frustrated beyond belief by your job, understand that you may be going through a professional midlife crisis. Listen to your inner voice and consider a midlife career change. Write down what you love to do as well as your strengths and weaknesses. Your passion and strengths will be your guide when considering a midlife career change.

Unless you have some sort of super anti-spam e-mail blocker installed on your computer, you have probably received e-mails with titles such as “Make $150,000 a year as an at home medical transcriptionist - no investment required”. Many of these e-mails are nothing but solicitations to try and get you to buy some sort of e-book, or other item, that will teach you how to become a medical transcriptionist. While remembering that many of these e-mails are nothing more than spam, it is equally important to remember that many of them are legitimate.

To start with, medical transcription is one of the fastest-growing of the medical related career fields. A study conducted about 6 years ago found that transcription, and related fields, would continue tremendous growth for many years to come. This is due in part to the rapid advance in the number of retiring “baby boomers”. As well, virtually all medical career fields are nearly recession proof, as no matter what the economic climate, people are always going to need medical care; thus, doctors and other medical professionals are always going to need medical transcriptionists.

In essence, a trained medical transcriptionist can take the notes (most commonly being voice recordings) of doctors, nurses, etc., and translate them into various forms, including medical reports, charts, etc. Potential medical transcriptionists will need good listening skills, as medical terminology may sound the same, but have different meanings depending upon the context in which it’s used. The final results of a medical transcriptionists work must be 100% accurate, as this work is what’s used to document a patient’s medical history. As well, a transcriptionist’s work may be utilized during certain legal proceedings, so everything must always be perfect. Legal matters can hinge entirely on the accuracy of the transcriptions. And, no matter what the outcome of the proceedings, all transcripts most generally become a matter of public record.

A medical transcriptionist is normally employed in one of the following 4 ways:

In an actual hospital
In a doctor’s office, clinic, or other outpatient medical care facility
In labs, medical schools, third-party transcription services, etc.
As independent or “home-based” medical transcriptionists

Most appealing to potential new transcriptionists is the possibility of working from home. While being home-based has its benefits, it has its challenges as well. The lack of a normal “9 to 5″ work schedule, and structured office environment are two good examples of such challenges. As well, if you decide to become home-based, you will likely need to form your own business legally, set up your tax requirements, etc. All of this is really not anywhere near as difficult as it may sound. But all potential home-based transcriptionists will want to keep these things in mind.

Culture provides the unwritten rules that inform and shape expected behaviors. To date, little research has been conducted into the attitudes or opinions that service personnel hold toward mental health issues. This article examines current literature and research into the recognition of mental health problems in the military and potential organizational barriers to care including stigma and the specific characteristics of a military culture such as the significant reliance on buddy support. We conclude that the barriers to care which operate in both military and civilian populations are not insignificant. Western militaries in fact currently face an uphill struggle to combat the substantial barriers to care that exist.

Military personnel are at a high risk of exposure to potentially traumatic events. As such, this makes tiiem an “atrisk group” who are vulnerable to suffering from psychological distress and mental health problems including depression, family violence, substance abuse, and post-traumatic stress disorder (PTSD), all of which are problems for the military services and a threat to occupational functionality.1 The impact of mental health on decision making is especially of significance given the high technology, fast-paced warfare of the 21st century, the battlefield which leaves little margin for error. Furthermore, many military forces have to cope with increasingly complicated conflicts with an ever decreasing number of soldiers available to fulfill these duties.2 Troops therefore need to function at peak efficiency and inefficiencies imposed by work stress and mental health problems may have very serious consequences.

Recent claims from soldiers and commanders inside the theaters of Iraq and Afghanistan have raised questions about the state of mental healtii in the U.K. military.4,5 This article attempts to explore the issue of military culture in relation to stress (traumatic or otiierwise) and examines how the military environment may exacerbate psychological problems because of barriers to care including stigma.

The Different Types of Stressors within a Military Environment

The potential of being exposed to traumatic stressors is an ever present issue for individuals who choose the military as their occupation. Furthermore, additional work-related stressors, such as length of deployment or exposure to adverse living condition, may exacerbate the effects of traumatic stress.3 In this section, relevant research on the two different types of stressors will be discussed.

Studies have shown that the degree of psychological trauma from operational duties is proportionally related to the type of warfare fought.6 One of the adverse outcomes of wartime trauma is PTSD. Rates of PTSD in combat veterans have been measured on numerous occasions and vary from 15 to 31%.7·8 These rates are in excess of the 2 to 3% prevalence of PTSD symptoms recorded in the U.K. general population.9 However, focusing on PTSD alone may not give the full picture of operationally induced psychological distress. For instance, it has been reported that up to 50% of Falkland War veterans have symptoms of PTSD even though they may not have sufficient or intense enough symptoms to warrant a formal diagnosis of PTSD.

Some of the variation in rates of PTSD and prevalence of traumatic stress symptoms may be accounted for by differences in study design. For instance, there are many types of instruments used to measure PTSD and many different ways of classifying military missions.11 Furthermore, questionnaires usually overestimate the prevalence of psychiatric conditions.12 Studies which use semistructured instruments such as the Clinician-Adniinistered PTSD Scale are likely to give a better estimate of the true prevalence figure. Studies also vary in their use of terminology and it is important to remember that suffering with PTSD symptoms does not always prevent individuals from working or having fulfilling social lives. Symptoms are not the same as disorder, altiiough it would be foolish to merely dismiss subdiagnostic symptoms as being irrelevant: they may well affect quality of life.

Aside from operationally related traumatic stress, there are numerous other work-related stressors which significantly affect the lives of service personnel. Pflanz et al.3 investigated sources of stress and their prevalence in the U.S. military. Significant work stress was reported by 26% of troops and another 15% described significant emotional distress related to work stressors. The study revealed tiiat being in combat, exposure to heavy casualties, and unexpected deployments all correlated with increased levels of psychological distress.

Mental disorders, whether they are the result of traumatic or work stressors, appear to have had a significant impact on manpower and retention rates. Hoge et al.1 conducted a population-based analysis of hospitalizations occurring at U.S. military medical facilities between 1990 and 1999 among active duty personnel. Results showed that mental disorders were the leading cause of medical discharge among men and the second leading category among women, accounting for 13% of all hospitalizations. Overall, 23% of all inpatient bed days were attributed to mental disorders.

To Successfully Execute the Mental Health Mission in Afghanistan

Disclaimer: The opinions or assertions are those of the author and do not necessarily reflect those of the Army Medical Department or the Department of Defense

Mental Health or Combat and Operational Stress Control (COSC) Teams have been deploying with infantry units to Afghanistan in support of Operation Enduring Freedom (OEF) since 2001. Consideration of the following seven areas will help future providers develop a comprehensive plan to successfully execute the mental health mission in Afghanistan.

The prospect of deployment tends to elicit an array of emotional responses. Investing energy in sound deployment planning will not only blunt this normal situationally-induced anxiety, but, perhaps more importantly, it will pay future dividends as the process forces one to develop a preliminary concept of operations for the mission.

* Know the mission. Participate in the pre-deployment site survey either by attending the actual visit or contacting the representative from your command to ensure that specific issues are investigated on your behalf. Obtain previous after action reviews and directly communicate with providers recently or currently assigned to your projected area of operations. Immediately establish relations with your future chain of command.

* Know the resources. You may be pleasantly surprised to identify personnel assets in theater that you were not expecting. Or, perhaps, there may be additional populations that you will unexpectedly inherit. Prepare for both scenarios.

* Know your team. If possible, assemble and work with your team prior to deployment. This will help build professional and personal relationships, while identifying areas of concern, potential personality conflicts or clinical training deficits prior to deploying.

* Procure psychoeducational materials and relevant training. If you have pamphlets, seminars and power-points already prepared, bring them. The Army Medical Department School at Fort Sam Houston offers the most up-to-date training in combat and operational stress control and a comprehensive DVD on a myriad of military specific mental health issues. Another useful resource for presentations and handouts is the US Army Center for Health Promotion and Prevention.

* Sharpen your skills. Many officers and enlisted technicians find themselves fulfilling non-clinical roles in garrison. Rest assured, you will be a clinician first in theater. You may negatively distinguish yourself if you arrive unprepared to do an intake, perform a command directed evaluation or maintain a modest case load. Expect the vast majority of clinical work to revolve around occupational discord, relationship problems, sleep difficulties, somatic complaints, and acute stress reactions, along with preexisting anxiety, mood and personality disorders. Take steps to improve or refresh your clinical skills, and the requisite supporting documentation to support same, before departure.

* Military basics. We often marginalize certain military tasks in garrison that are everyday activities in theater. To avoid embarrassment, understand command and rank structure, and become fluent in the negotiations needed between different branches of service. Arrive in good physical condition, qualified on your weapon with good command of clearing and cleaning procedures, and with a solid foundation of terminology, equipment and basic tasks, such as assembling body armor and protective gear.

2. Command Delineation

Mental health missions in the deployed environment are ever-increasingly joint service endeavors. Further contributing to a convoluted chain of command, your unit may relinquish various elements of command to different agencies. For example, in OEF VII, the Division Mental Health Service (DMHS) from the 10th Mountain Division, Fort Drum, NY arrived in theater for a 12-month deployment in early February 2006. The company to which DMHS was assigned maintained administrative control, but ceded operational control to the 14th Combat Support Hospital. Shortly thereafter, an Air Force combat stress team arrived in theater, followed by a small Brigade mental health team. Three mental health officers in-charge and four chains of command often confused units and providers downrange, not to mention the teams themselves. Establishing clear roles and expectations is vital. Do not wait for others to complete this essential task for you - chaos can result if these relationships are not clarified early in your deployment.

3. Combat and Operational Stress Control

The current concepts of combat and operational stress control comprise the foundation of mental health services in OEF. The country of Afghanistan has a larger geographic area and population than Iraq. Further, the climate and geography vary considerably. From scalding desert, and high plains and insulated valleys, to rugged mountainous terrain, the theater itself presents an array of novel challenges. To cover large areas of logistical and operational importance, rustic forward operating bases and firebases are strategically placed throughout the theater. Due to mission demands and personnel limitations, it is impossible to staff each outpost with mental health providers. Hence, the concept of the mobile mission, stressing resiliency and preventative services at forward locations, was born. Mobility is critical to mission success in OEF.

Abstract and case study poster sessions will be conducted during the College of American Pathologists’ Annual Meeting (CAP ‘07), which is scheduled for September 30 to October 3, 2007. The meeting will occur at the Sheraton Chicago Hotel & Towers, Chicago, Ill. The poster sessions will occur in the Connection Café and Exhibit Hall. Specific dates and times for each poster session are listed below. Also shown below each poster session listing are the subject areas that will be presented during each session.

POSTER SESSION 100: SUNDAY, SEPTEMBER 30, 2007, 10:00 AM-12:30 PM

Informatics; Hematopathology

Synoptic Reporting of Cancer Resection Specimens Using a Synoptic Tool: A 3-Year Experience With More Than 7500 Specimens

Anil V. Parwani, MD, PhD1 (parwaniav@upmc.edu); Ronald Angeles, MD1; Anthony Piccoli, BS1; Sharon Winters, MS2; Samuel Yousem, MD1; Michael Becich, MD, PhD.3 Departments of 1Pathology and 2Cancer Registry, University of PittsburghMedical Center, Pittsburgh, Pa; 3Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pa.

Context: Cancer checklists comprising standardized data elements are valuable tools that clinicians use to guide them in managing patients. We describe our experience with the use of Synoptic Worksheet entry tool for multiple malignant resections and also describe the use of synoptics in providing reports in our clinical environment of multiple academic and community centers.

Design: We used a synoptic reporting tool as part of existing laboratory information system, CoPathPlus, from Cerner DHT Corp. We modified the College of American Pathologists checklists into worksheets for select organ systems and malignancies. The synoptics have been in use for 40 months in our laboratory information system. The data were present as discrete data elements. A data element, that is, tumor type, is in the value dictionary under the value of tumor type, allowing users to search for cases that have that value point populated.

Results: A total of 7626 specimens in our network had synoptic report completed. Breast (1534), prostate (1373), colorectum and appendix (673), lung (606), and melanoma (533) were the most used templates in the system. Rarer malignancies including parathyroid and adrenal cortical carcinoma, penile tumor, and gallbladder tumors had fewer synoptic templates in the system (Table).

Conclusions: Use of the new synoptic report minimizes transcription errors, enables quicker access to information, and improves communication for cancer management. Such uniformity lends itself to ease of data viewing and extraction, as demonstrated by rapid production of standardized, high-quality data from these malignant resection specimens.

This work is partially supported by College of American Pathologists Foundation Rippey Grant for Quality Assurance.

Analysis of a Standardized Colorectal Cancer Resection Reporting Process in a Subspecialized Academic Pathology Department

(Poster No. 2)

Chad R. Rund, DO (rundcr@upmc.edu); Sharon B.Winters, MS, RHIA, CTR; Anthony L. Piccoli, BS; Anil V. Parwani, MD, PhD. Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pa.

Context: University of Pittsburgh Medical Center (UPMC) use (Cerner’s CoPathPlus) of reporting College of American Pathologists (CAP) colorectal resection synoptic defined clinical elements was studied. Specific aims included (1) does UPMC synoptic use reflect the CAP requirements, (2) are CAP checklists more accurate and complete than traditional reports, and (3) will pathologists routinely use the checklists.

Design: Fifty random colorectal synoptics were chosen and evaluated for accuracy with respect to the 15 CAP scientifically validated elements (2005). Synoptics were compared with final text diagnoses and comments and codes were assigned according to completeness and accuracy. Textbased and synoptic values were assessed for the same cases but not at the individual pathologist level.

Code 0: synoptic value completed but not matching final text diagnosis

Code 1: . . . completed and matches

Code 2: . . . completed and matches comment only

Code 3: . . . completed but not in final diagnosis or comment

Code 4: . . . not completed but available in final diagnosis

Code 5: . . . not completed but available in comment only

Code 6: . . . not completed or available in final diagnosis or comment

Hughes’ outline of modern psychiatry, 5th ed.

Gill, David.

John Wiley & Sons

2007

415 pages

$45.00

Paperback

RC456

This book is an overview of current psychiatry practices in the UK, covering classification, causes and prevention of disorders, history- taking, and mental state examination and investigation. Gill (psychiatry, Lister Hospital, Stevenage: Hertfordshire Partnership NHS Trust) outlines each of the major syndromes, in addition to types of treatment and the psychiatry of special age groups and populations. Case histories are included. This edition has been revised and updated to reflect recent research findings, changes in classification and terminology, and new organizational structures within the National Health Service and the implications of the Mental Health Act. The book is meant for medical students and trainee and practicing psychiatrists.

A nurse hands a breast cancer patient a seven-page, single-spaced consent form describing the potential risks of an experimental treatment. The patient signs on the line, indicating she understands the possible dangers of unproven cancer therapy But does she really?

Two new studies raise troubling questions about the way researchers and physicians gather informed consent for experimental and routine medical procedures. In the first study, Terry C. Davis of the Louisiana State University Medical Center in Shreveport and her colleagues recruited 183 people, including 53 who had cancer or another medical condition.

The researchers gave the participants an adult literacy test. They discovered that, on average, the recruits were reading at a 7th to 8th grade level. Next, the team gave 69 participants an informed consent form that had been used in a cancer treatment study. The form had been written at a 16th grade level.

The remaining 114 people got a consent form written at a 7th grade level. The researchers gave all the recruits time to read the forms and then interviewed them about the contents.

Most people preferred the simplified form, the researchers found. However, those who read the easier version didn’t seem to gain any better understanding of the implications of the experimental treatment, “It really didn’t improve comprehension,” Davis told Science News.

About 90 million adults in the United States have literacy skills ranking below 7th grade, the authors note. “Our findings raise ethical and legal questions about the ability of informed consent documents to aid all individuals in the decision-making process for study participation,” the authors say in the May 6 Journal of th National Cancer Institute.

A second study suggests that forms used by hospitals to obtain consent for routine surgical procedures are needlessly complex.

Kenneth D. Hopper of the Pennsylvania State University College of Medicine in Hershey and his colleagues studied 616 hospital consent forms. They found that 25 percent of the forms assumed that patients have college-level skills and 9 percent required postgraduate education in order to fully understand the risks and benefits of a given procedure.

Even so, the team found that many forms didn’t give patients enough information to make an informed decision about a procedure. The study appears in the May issue of Surgery.