Medical transcriptionists, sometimes referred to as healthcare documentation specialists, listen to voice recordings that physicians and other healthcare workers make and convert them into written reports. They also may review and edit medical documents created using speech recognition technology. Transcriptionists interpret medical terminology and abbreviations in preparing patients’ medical histories, discharge summaries, and other documents.

Duties

Medical transcriptionists typically do the following:

  • Listen to the recorded dictation of a doctor or other healthcare worker
  • Interpret and transcribe the dictation into patient history, exam notes, operative reports, referral letters, discharge summaries, and other documents
  • Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and consistent in style
  • Translate medical abbreviations and jargon into the appropriate long form
  • Identify inconsistencies, errors, and missing information within a report that could compromise patient care
  • Follow up with the healthcare provider to ensure that reports are accurate
  • Submit health records for physicians to approve
  • Follow patient confidentiality guidelines and legal documentation requirements
  • Enter medical reports into electronic health records (EHR) systems
  • Perform quality improvement audits

Traditionally, medical transcriptionists used audio playback equipment to listen to an entire dictation in order to produce a transcribed report, and some transcription is still done this way. It has become more common for medical documents to be prepared using speech recognition technology, in which specialized software automatically prepares an initial draft of a report. The transcriptionist then listens to the voice file and reviews the draft for accuracy, identifying any errors and editing the report, when necessary. Transcriptionists use word-processing and other specialized software to prepare the transcripts, as well as medical reference materials when needed.

Medical transcriptionists must be familiar with medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. Their ability to understand what the healthcare worker has recorded, correctly transcribe that information, and identify any inaccuracies in the transcript is critical to reducing the chance that patients will get ineffective or even harmful treatments. Medical transcriptionists also may need to be familiar with EHR systems.

Medical transcriptionists who work in doctors’ offices may have other duties, such as answering phones and greeting patients.

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Work Environment

Medical transcriptionists held about 58,000 jobs in 2018. The largest employers of medical transcriptionists were as follows:

Administrative and support services 33%
Offices of physicians 23
Hospitals; state, local, and private 21
Self-employed workers 6
Medical and diagnostic laboratories                        2

Administrative and support services includes companies that provide transcription services.

Medical transcriptionists may work from home, receiving dictation and submitting drafts electronically.

Work Schedules

Most medical transcriptionists work full time. Medical transcriptionists who work from home may work outside typical business hours and/or may have some flexibility in determining their schedules. Their work can be stressful because they need to ensure that reports are accurate within a quick turnaround time.

Education and Training

Medical transcriptionists typically need postsecondary education. Some choose to become certified.

Education

Employers prefer to hire transcriptionists who have completed postsecondary education in medical transcription, which is offered by vocational schools, community colleges, and distance-learning programs. Medical transcription programs are typically 1-year certificate programs, although there are also associate’s degree programs.

Programs normally include coursework in anatomy, medical terminology, risk management, legal issues relating to healthcare documentation, and English grammar and punctuation. Many of these programs include supervised on-the-job experience. Some transcriptionists, especially those already familiar with medical terminology from previous experience as a nursing assistant or medical secretary, become proficient through refresher courses and training.

Licenses, Certifications, and Registrations

Although certification is not required, some medical transcriptionists choose to become certified. The Association for Healthcare Documentation Integrity offers the Registered Healthcare Documentation Specialist (RHDS) and the Certified Healthcare Documentation Specialist (CHDS) certifications. Both certifications require passing an exam and periodic retesting or continuing education.

The RHDS certification, formerly known as the Registered Medical Transcriptionist (RMT), is for recent graduates with less than 2 years of experience and who work in a single specialty environment, such as a clinic or a doctor’s office.

The CHDS certification, formerly known as the Certified Medical Transcriptionist (CMT), is for transcriptionists who hold the RHDS designation. In addition, CHDS candidates must have at least 2 years of acute care experience, including experience handling dictation in various medical specialties.

To maintain certification, medical transcriptionists must complete continuing education requirements every 3 years.

Personality and Interests

Medical transcriptionists typically have an interest in the Building and Organizing interest areas, according to the Holland Code framework. The Building interest area indicates a focus on working with tools and machines, and making or fixing practical things. The Organizing interest area indicates a focus on working with information and processes to keep things arranged in orderly systems.

If you are not sure whether you have a Building or Organizing interest which might fit with a career as a medical transcriptionist, you can take a career test to measure your interests.

Medical transcriptionists should also possess the following specific qualities:

Computer skills. Medical transcriptionists must be comfortable using computers and word-processing software, because those tools are an essential part of their jobs. Transcriptionists may also need to know how to operate electronic health records (EHR) systems.

Critical-thinking skills. Transcriptionists must be able to assess medical reports and spot any inaccuracies and inconsistencies in finished drafts. They must also be able to think critically when doing research to find the information that they need and to ensure that sources are both accurate and reliable.

Listening skills. Transcriptionists must listen carefully to dictation from physicians. They must be able to hear and interpret the intended meaning of the medical report.

Time-management skills. Because dictation must be done quickly, medical transcriptionists must be comfortable working under short deadlines.

Writing skills. Medical transcriptionists need a good understanding of the English language and grammar.

Pay

The median annual wage for medical transcriptionists was $33,380 in May 2019. The median wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $22,160, and the highest 10 percent earned more than $51,260.

In May 2019, the median annual wages for medical transcriptionists in the top industries in which they worked were as follows:

Medical and diagnostic laboratories $41,660
Hospitals; state, local, and private 39,850
Offices of physicians 35,560
Administrative and support services                          26,700

Some medical transcriptionists are paid based on the volume of transcription they produce. Others are paid an hourly rate or an annual salary.

Most medical transcriptionists work full time. Medical transcriptionists who work from home may work outside typical business hours and/or have some flexibility in determining their schedules. Their work can be stressful because they need to ensure that reports are accurate within a quick turnaround time. 

Job Outlook

Employment of medical transcriptionists is projected to decline 3 percent from 2018 to 2028. Technological advances have changed the way medical transcription is done. Speech recognition and electronic health records (EHR) software advances often allow physicians to create some of this documentation in the moment, reducing the need for transcriptionists.

The aging population and growing rates of chronic conditions will continue to increase demand for healthcare services. This will result in a growing number of medical tests and procedures, all of which will require transcription. However, technological advances, such as speech recognition software, allow transcriptions to be prepared by fewer medical transcriptionists. 

As healthcare providers seek to cut costs, some will contract out transcription services and not do transcription in-house. Some of this work may be outsourced to other countries, which would reduce domestic employment.

For More Information

For more information about medical transcriptionists and for a list of accredited medical transcription programs, visit

Association for Healthcare Documentation Integrity

 

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