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Medical Transcription Basics

 

 

What is Medical Transcription

Medical transcription, also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals into text format. The evolution of the transcription dates back to the 1960s. The method was designed to assist in the manufacturing process. The first transcription that was developed in this process was MRP, which is the acronym for Manufacturing Resource Planning, in 1975. This was followed by another advanced version namely MRP2. But none of them yielded the benefit of medical transcription.

 

 

However, transcription equipment has changed from manual typewriters to electric typewriters to word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings. Today, voice recognition system (VRS) is increasingly being used, with medical transcriptionists and or "correctionists" providing supplemental editorial services, although there are occasional instances where VRS fully replaces the MT. Natural-language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide (although MTs do).

 

How to Become a Medical Transcriptionist

Any degree holder with good communication skills can learn and become a medical transcriptionist. The course assists you in acquiring the required skills and mounting the existing ones. There are several types of practice sessions where the student can perform by listening to the tapes of Doctors dictated. This is an important part of the curriculum since most of the work of a medical transcriptionist is outsourced.

 

How to become a certified Medical transcriptionist

Becoming Certified

 

The most important consideration in finding successful employment in the Medical Transcription industry is your skill set. Certification, while not essential, can be very helpful in advancing a career in Medical Transcription. When people speak of certification in the Medical Transcription field, they are typically referring to certification with the AAMT (American Association of Medical Transcriptionists). The official designation of the AAMT certification is "CMT" - Certified Medical Transcriptionist.

 

While the CMT is certainly highly regarded, it is by no means a prerequisite for entry into, or advancement within the field of medical transcription. Many competent transcriptionists do not have the designation. However, if your time and resources permit, it is something that should be seriously considered.

The CMT credential is particularly important for those interested in pursuing a management level or supervisory position in the industry.

 

Basic MT knowledge, skills and abilities

  • Knowledge of basic to advanced medical terminology is essential.
  • Knowledge of anatomy and physiology.
  • Knowledge of disease processes.
  • Knowledge of medical style and grammar.
  • Average verbal communication skills.
  • Above-average memory skills.
  • Ability to sort, check, count, and verify numbers with accuracy.
  • Demonstrated skill in the use and operation of basic office equipment/computer.
  • Ability to follow verbal and written instructions.
  • Records maintenance skills or ability.
  • Above-average typing skills.
  • Knowledge and experience transcribing (from training or real report work) in the Basic Four work types:

             History and Physical Exam, Consultation, Operative Report, and Discharge Summary.

  • Knowledge of and proper application of grammar.
  • Knowledge of and use of correct punctuation and capitalization rules.
  • Demonstrated MT proficiencies in multiple report types and multiple specialties.

 

Medical transcriptionist roles and responsibilities

  • Accurately transcribes the patient-identifying information such as name and Medical Record or Social Security

             Number.

  • Transcribes accurately, utilizing correct punctuation, grammar and spelling, and edits for inconsistencies.
  • Maintains/consults references for medical procedures and terminology.
  • Keeps a transcription log.
  • In some countries, MTs may sort, copy, prepare, assemble, and file records and charts (though in the United

             States (US) the filing of charts and records are most often assigned to Medical Records Techs in Hospitals or

             Secretaries in Doctor office.

  • Distributes transcribed reports and collects dictation tapes.
  • Follows up on physicians' missing and/or late dictation, returns printed or electronic report in a timely fashion

             (in US Hospital MT Supervisor performs).

  • Performs quality assurance check.
  • May maintain disk and disk backup system (in US Hospital, MT Supervisor performs).
  • May order supplies and report equipment operational problems (In US, this task is most often done by Unit

             Secretaries, Office Secretaries, or Tech Support personnel).

  • May collect, tabulate, and generate reports on statistical data, as appropriate (in US, generally performed by

             MT Supervisor).

 

Getting Certified

Becoming a CMT requires an investment - both in time and money.

The CMT exam is a two part exam. Each part must be taken separately and each requires the payment of a fee. You are required to pass Part I before sitting for Part II.

 

Part I

 

The first part of the exam is a multiple-choice, objective examination. This exam measures overall competence in the foundation knowledge required to be a successful medical transcriptionist. Test sections and weighting are as follows: Medical Terminology (30%), English Language and Usage (25%), Anatomy & Physiology (20%), Disease Processes (15), Healthcare Record (5%), and Professional Development (5%). The exam consists of 120 multiple choice questions in the 6 major content areas listed above. The exam is administered electronically on touch-screen computers. The time allowed for this exam is 3 hours. No reference materials are permitted in the testing center.

 

Scheduling the Exam

This exam is administered year-round at nationwide testing centers. Exams can be scheduled by calling 1-800-274-8719 or 610-617-9300. Alternatively, information can be obtained from the Medical Transcription Certification Commission (an AAMT organization) by calling 1-800-578-9823. The exam is open to anyone who feels prepared to take it. Self assessment tools are available from AAMT.

 

Exam Fee

This exam fee for Part I of the CMT is currently $150. The same fee applies to retakes.

 

Part II

The second part of the CMT exam is a transcription exam. This is a rigorous, competency based exam that tests an applicant's ability to accurately and proficiently transcribe physician dictation. This exam is administered in a controlled setting and requires several years of experience transcribing a broad array of complex medical records. The exam consists of approximately 15 minutes of dictation representing a broad cross section of report types and specialties. Applicants are allowed 2 hours for this portion of the exam. Reference materials, notes, spellcheckers, and abbreviation expanders are permitted.

 

Scheduling the Exam

This exam is offered several times per year and must be scheduled in advance by calling the Medical Transcription Certification Commission at 1-800-578-9823 or e-mailing them at mtcc@aamt.org. The exam is available for anyone who has successfully passed the Part I exam within the previous two years.

 

Exam Fee

This exam fee for Part II of the CMT is currently $100 for Members and $150 for Non-Members w

 

ithin the US; $200 for Members and $250 for Non-Members outside of the US. The same fee applies to retakes.

Preparing for the Exam Of course, the best preparation for the CMT exam is a number of years of intensive experience transcribing medical records reports for a hospital or medical transcription service provider. Many graduates of medical transcription training programs elect to sit for Part I of the exam shortly after completing their training - while the foundation material is still fresh in their minds. Part II of the exam, however, requires a significant amount of practical experience.

 

AAMT also offers a number of self-assessment products that can be purchased in advance of taking the exam. These are essentially simulated tests that allow a prospective candidate to assess whether they are ready to take the actual exam. These practice tests also help prepare a person for the actual exam exp

 

erience. Self-assessment simulation exams are available for both Part I and Part II and can be purchased on-line at www.aamt.org.

 

Maintaining the Certification

In order to maintain the CMT designation a transcriptionist must continue to demonstrate progress in the field by periodically fulfilling approved continuing education requirements.

 

Getting More Information

AAMT offers an overview of the certification process on its web site. Go to www.aamt.org and click the "certification" button.

 

 

 

Industry trends and potential treats

According to the Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2002-03 Edition,   Medical Transcription will continue to be a growing field in the US through 2010. "Employment of medical transcriptionists is projected to grow faster than the average for all occupations through 2010. Demand for medical transcription services will be spurred by a growing and aging population. Older age groups receive proportionately greater numbers of medical tests, treatments, and procedures that require documentation."

Future of Medical Transcription

The medical transcription industry will continue to undergo metamorphoses based on many contributing factors like advancement in technology, practice workflow, regulations, etc. The evolution toward the electronic patient record demonstrates that, over time, documentation habits will change either through standards and regulations or through personal preferences. Until recently, there were few standards and regulations that MTs and their employers had to meet. First, there was the Health Insurance Portability and Accountability Act (HIPAA). It wasn't long ago that "experts" stated that HIPAA would not have any effect on the medical transcription industry. Either in a state of denial or ignorance of the law, many transcriptionists and companies have continued on their existing course of providing medical transcription. Many providers are concerned that the majority of the transcription industry will not be able to meet several specific requirements: namely, access controls, policies and procedures, and audits of access to the patient information. Without the knowledge or resources to comply, many in the industry are claiming to comply and signing their Business Associates Agreements without taking the security measures required. Many are uninformed, and some are choosing to remain so, believing that the world of transcription cannot possibly be expected to make these adaptations. The fact is that the employees will demand HIPAA compliance and will change employers and contractors when they don't get it. There will also be demands to enhance patient safety, increase efficiency, and reduce costs. It is mandatory for service providers and healthcare practices to migrate to a HIPAA-compliant environment.

 

 

     

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