About Medical Transcription Services: The Basics of a Medical Transcription Service

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After patient visits, physicians create notes regarding treatment, observations, and more. In the past, these notes were handwritten to be included in the patient's file. Technology allowed doctors to begin dictating these notes via a handheld recorder. For decades, this meant physical tapes, but in recent years, most doctors switched to creating digital recordings.

Of course, the patient's file still needs a written record of these voice-recorded notes. The solution was to have someone physically transcribe these recordings. Medical transcription is a highly specific skill, requiring acute hearing, fast yet accurate typing, and a decent knowledge of medical terminology. Originally, medical providers hired medical transcriptionists as direct employees of the clinic or hospital. However, as technology continued improving, healthcare providers began outsourcing this function to companies and individuals who specialize in medical transcription as a cost-effective means of creating accurate records of doctors' dictated notes.

What is Medical Transcription?

At its most basic level, medical transcription is the typing of dictated medical reports. Healthcare providers, including doctors and nurses, dictate these reports, which are then uploaded digitally via Internet or smartphone app, or created over the phone, to the transcriptionist who creates a written record of the dictation.

Medical providers record their audio files via a variety of devices, including handheld recorder, smartphone and iPhone apps, and phone calls to voice servers. Dictated reports include chart reviews, ER visits, office visits, diagnostics, operations, and final summaries. The transcriptionist listens to this audio report and types it out, typically into a Word document. He or she then forwards the transcribed document to the physician, usually electronically.

Once the doctor approves the document, it enters the patient's medical record, referred to by every future healthcare provider who treats the patient.

Recording Methods Physicians Use to Dictate Notes

Most physicians choose either handheld digital recorders or toll-free phone lines to dictate their patient notes. Most medical transcription services support both recording methods.

Each option offers an easy way to create multiple recordings in a single session. In addition, both options allow you to use a cell phone, making them convenient and portable. There are only two real differences between the two methods. Toll-free phone lines don't require the investment that a handheld digital recorder does. However, the digital recorder typically creates a cleaner, crisper recording. Since clear recordings are easier to transcribe, you tend to save money in the long run by investing in a handheld digital recorder.

A third option is using a handheld cassette recorder for dictating notes. However, fewer healthcare providers use this option these days, since many transcription services no longer accept these tapes for transcription (today, it's nearly impossible to find a transcription machine that takes tapes). Of course, any medium that allows you to create a recording, including CDs and DVDs, works for dictation. However, the trick is finding a transcription service that works with these media. Talk to your representative about recording methods and which is the preferred option.

How Do You Transfer Recordings and Transcriptions?

Medical transcription requires two layers of record transfer. First, the healthcare provider must get the recording to the transcriptionist. Then, the transcriptionist must get the transcribed document back to the healthcare provider. Whichever transfer method you use must include HIPAA-compliant security methods to protect the patient's information.

Transfer digital recordings via the Internet. Choices include encrypted email (encryption is necessary to remain HIPAA compliant), a secure website, FTP (file transfer protocol), or transcription software used by the service. If you use telephone-based dictation, the recording goes directly to the provider's server. This does not require encryption.

Transcription of the voice recording typically occurs in Microsoft Word, which allows easy conversion into whatever format the client prefers, such as PDF. From there, the client (the healthcare provider) integrates the file into the patient's records. If you request it, the transcription service may also print and mail files, and some even offer fax delivery. However, the most common method by far is electronic transfer, typically via the same delivery method used to send the digital file: encrypted email, secure website, FTP, or transcription software.

Some medical transcription services offer an online storage system for recordings and transcripts. If your practice doesn't use its own document management software, you may want to take advantage of this system, which organizes and tracks files according to your criteria (by date, doctor, or patient). Most transcription services charge for this, but you may find the content management fee worth it if you don't have your own system.

Why You Should Hire a Professional Medical Transcriptionist

Whether you choose to staff an in-house team, hire a transcription service, or go with a freelance transcriptionist, you want someone experienced with medical transcription. Fast, accurate typing isn't enough to create quality documents from a provider's recorded notes. The best medical transcriptionists are familiar with medical terminology, which is important when so many terms sound similar yet have opposite meanings (such as hypertension and hypotension). You're also trusting your transcriptionist to protect patient records, respect privacy, and help you maintain HIPAA compliance. Make sure you hire someone who is qualified and capable of fulfilling all of these requirements.

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