Doctors and other health care professionals often make tape recordings documenting what happened during their patients’ appointments or surgical procedures. Medical transcriptionists listen to these tapes and transcribe, or type, reports of what the doctor said. The reports are then included in patients’ charts. Medical transcriptionists work in a variety of health care settings, including hospitals, clinics, and doctors’ offices, as well as for transcription companies or out of their own homes. There are approximately 105,000 medical transcriptionists working in the United States. Medical transcriptionists are also called medical transcribers, medical stenographers, or medical language specialists.
Medical Transcriptionist Career History
Health care documentation dates back to the beginnings of medical treatment. Doctors used to keep their own handwritten records of a patient’s medical history and treatment. After 1900, medical stenographers took on this role. Stenographers worked alongside doctors, writing down doctors’ reports in shorthand. This changed with the invention of the dictating machine, which led to the development of the career of medical transcription.
The first commercial dictating machine, using a wax cylinder record, was produced in 1887. It was based on Thomas A. Edison’s phonograph invented in 1877. Technology has come a long way since then. Recent advances in the field include Internet transcription capabilities and voice (or speech) recognition software. The latter electronically transcribes recorded spoken word, which means that a medical transcriptionist does not have to type out all the dictation. Given the complexity of medical terminology, however, voice recognition programs are likely to make mistakes, so there is still plenty of work for the medical transcriptionist, who must carefully proofread the report to catch and correct any errors.
Medical Transcriptionist Job Description
Medical transcriptionists transcribe (type into printed format) a dictated (oral) report recorded by a doctor or another health care professional. They work for primary care physicians as well as health care professionals in various medical specialties, including cardiology, immunology, oncology, podiatry, radiology, and urology. The medical transcriptionist usually types up the report while listening to the recording through a transcriber machine’s headset, using a foot pedal to stop or rewind the recording as necessary. Some doctors dictate over the telephone, and others use the Internet.
The report consists of information gathered during a patient’s office appointment or hospital visit and covers the patient’s medical history and treatment. Doctors dictate information about patient consultations, physical examinations, results from laboratory work or X rays, medical tests, psychiatric evaluations, patient diagnosis and prognosis, surgical procedures, a patient’s hospital stay and discharge, autopsies, and so on. Often doctors will use abbreviations while dictating. The medical transcriptionist must type out the full names of those abbreviations.
Because the report becomes a permanent part of a patient’s medical record and is referred to by the same doctor or other members of the patient’s health care team during future office visits or when determining future medical treatment, it must be accurate. This includes dates and the spelling of medications, procedures, diseases, medical instruments and supplies, and laboratory values.
After typing up a report, medical transcriptionists review it and make corrections to grammar, punctuation, and spelling. They read it to be sure it is clear, consistent, and complete and does not contain any errors. Medical transcriptionists are expected to edit for clarity and make grammar corrections; therefore, the final report does not need to be identical to the original dictation in those respects.
Being a medical transcriptionist is not all about typing and proofreading. Medical transcriptionists are very familiar with medical terminology. When recording their reports, doctors use medical terms that are relevant to a patient’s condition and treatment. Such terms might be names of diseases or medications. Medical transcription-ists understand what these medical terms mean and how they are spelled. They understand enough about various diseases and their symptoms, treatments, and prognoses as to be able to figure out what a doctor is saying if the recording is a little garbled. They have a good understanding of medicine and know about human anatomy and physiology. If what the doctor says on the tape is unclear, a medical transcriptionist often has to determine the appropriate word or words based on the context. However, medical transcriptionists never guess when it comes to medications, conditions, medical history, and treatments. A patient could receive improper and even damaging treatment if a diagnosis is made based on a report containing errors. Medical transcriptionists contact the doctor if they are uncertain or they leave a blank in the report, depending on the employer’s or client’s expectations and guidelines. After the medical transcriptionist reviews the report, it is given to the doctor, who also reviews it and then signs it if it is acceptable—or returns it to the transcriptionist for correction, if necessary. Once it has been signed, the report is placed in the patient’s permanent medical file.
Many medical transcriptionists use voice recognition software to electronically create documents from oral dictation, eliminating much of their typing work. Medical transcriptionists still have to review the transcription for accuracy and format.
While some transcriptionists only do transcribing, other transcriptionists, often those who work in doctors’ offices or clinics, may have additional responsibilities. They may deal with patients, answer the phone, handle the mail, and perform other clerical tasks. And transcriptionists may be asked to file or deliver the reports to other doctors, lawyers, or other people who request them.
A growing number of medical transcriptionists work out of their homes, either telecommuting as employees or subcontractors or as self-employed workers. As technology becomes more sophisticated, this trend is likely to continue. Medical transcriptionists who work out of their homes have some degree of mobility and can live where they choose, taking their jobs with them. These workers must keep up-to-date with their medical resources and equipment. Because terminology continues to change, medical transcriptionists regularly buy revised editions of some of the standard medical resources.
Medical Transcriptionist Career Requirements
English and grammar classes are important in preparing you to become a medical transcriptionist. Focus on becoming a better speller. If you understand the meanings of word prefixes and suffixes (many of which come from Greek and Latin), it will be easier for you to learn medical terminology, since many terms are formed by adding a prefix and/or a suffix to a word or root. If your high school offers Greek or Latin classes, take one; otherwise, try to take Greek or Latin when you continue your studies after high school.
Biology and health classes will give you a solid introduction to the human body and how it functions, preparing you to take more advanced classes in anatomy and physiology after you graduate. Be sure to learn how to type by taking a class or teaching yourself. Practice typing regularly to build up your speed and accuracy. Word-processing and computer classes are also useful.
Some junior, community, and business colleges and vocational schools have medical transcription programs.
You can also learn the business of medical transcription by taking a correspondence course. To be accepted into a medical transcription program, you might need to have a minimum typing speed. The American Association for Medical Transcription (AAMT) recommends that medical transcriptionists complete a two-year program offering an associate’s degree, but this is not necessary for you to find a job.
You should take courses in English grammar as well as medical terminology, anatomy, physiology, and pharmacology. Some of the more specific classes you might take include Medicolegal Concepts and Ethics, Human Disease and Pathophysiology, Health Care Records Management, and Medical Grammar and Editing. Certain programs offer on-the-job training, which will help when you are looking for full-time employment.
The AAMT has a mentoring program for students who are studying medical transcription. Students can make important contacts in the field and learn much from experienced professionals.
Certification or Licensing
The Medical Transcription Certification Commission (MTCC) of the AAMT administers a certification examination that tests applicants on their medical transcription-related knowledge and transcription performance. Those who pass the exam become certified medical transcriptionists (CMTs). Certification is good for three years, at which point recertification is necessary to keep the CMT designation. At least 30 hours of continuing education credits are required every three years.
While medical transcriptionists do not need to be certified to find a job, it is highly recommended as a sign of achievement and professionalism. CMTs will probably more readily find employment and earn higher salaries.
A love of language and grammar is an important quality, and accuracy and attention to detail are absolute musts for a medical transcriptionist. It is essential that you correctly type up information as spoken by the doctor on the tape recording. You must be able to sift through background sounds on the tape and accurately record what the doctor says. Doctors dictate at the same time they are with a patient or later from their office or maybe even as they go about their daily routine, perhaps while eating, driving in traffic, or walking along a busy street. In each of these cases, the recording will likely include background noises or conversations that at times drown out or make unclear what the doctor is saying.
Many doctors grew up outside of the United States and do not speak English as their first language, so they may not have a thorough understanding of English or they may speak with an accent. You must have a good ear to be able to decipher what these doctors are saying.
In addition to having accurate typing skills, you will also need to type quickly if you want to earn higher wages and get more clients. A solid understanding of word-processing software will help you to be more productive. An example of this is the use of macros, or keystroke combinations that are used for repetitive actions, such as typing the same long, hard-to-spell word or phrase time and again. If you suffer from repetitive strain injuries, then this would not be a suitable profession.
Flexibility is also important because you must be able to adapt to the different skills and needs of various health care professionals.
Medical transcriptionists should be able to concentrate and be prepared to sit in one place for long periods at a time, either typing or reading. For this reason, it is important that you take regular breaks. An ability to work independently will help you whether you are self-employed or have an office position, since you do most of your work sitting at a computer.
Medical transcriptionists are required to keep patient records confidential, just as doctors are, so integrity and discretion are important.
Exploring Medical Transcriptionist Career
There is plenty of accessible reading material aimed at medical transcriptionists. This is a good way to learn more about the field and decide if it sounds interesting to you. Several of the Web sites listed at the end of this article feature self-tests and articles about medical transcription. Marylou Bunting, a home-based certified medical transcriptionist, recommends that you get a medical dictionary and PDR (Physicians’ Desk Reference) to familiarize yourself with terminology. See if your local library has the Journal of the American Association for Medical Transcription and browse through some issues. The Internet is a great resource for would-be medical transcriptionists. Find a bulletin board or mailing list and talk to professionals in the field, perhaps conducting an informational interview.
Bunting also suggests that you “put yourself in a medical setting as soon and as often as you can.” Ask if your doctor can use your help in any way or apply for a volunteer position at a local hospital. Ask to be assigned to the hospital’s medical records department, which won’t give you the opportunity to transcribe, but will give you some experience dealing with medical records.
According to the Occupational Outlook Handbook, there are about 105,000 medical transcriptionists working in the United States. About 40 percent work in hospitals and 30 percent work in doctors’ offices and clinics. Others work for laboratories, home health care services, medical centers, colleges and universities, medical libraries, insurance companies, transcription companies, temp agencies, and even veterinary facilities. Medical transcriptionists can also find government jobs, with public health or veterans hospitals.
It can be difficult to get started in this field, especially if you do not have any work experience. Some medical transcriptionists start out working as administrative assistants or receptionists in doctors’ offices. They become acquainted with medical terminology and office procedures, and they make important contacts in the medical profession. According to AAMT, a smaller doctor’s office may be more apt to hire an inexperienced medical transcriptionist than a hospital or transcription service would be.
Marylou Bunting recommends that you try to get an informal apprenticeship position since on-the-job experience seems to be a prerequisite for most jobs. Or perhaps you can find an internship position with a transcription company. Once you have some experience, you can look for another position through classified ads, job search agencies, or Internet resources. You can also find job leads through word-of-mouth and professional contacts. The AAMT Web site features job postings. In fact, AAMT is an invaluable resource for the medical transcriptionist. Local chapters hold periodic meetings, which is a good way to network with other professionals in the field.
There are few actual advancement opportunities for medical transcriptionists. Those who become faster and more accurate will have an easier time securing better-paying positions or lining up new clients. Skilled and experienced medical transcriptionists can become supervisors of transcription departments or managers of transcription companies, or they might even form their own transcription companies. Some also become teachers, consultants, or authors or editors of books on the subject of medical transcription.
Medical transcriptionists are paid in a variety of ways, depending on the employer or client. Payment might be made based on the number of hours worked or the number of lines transcribed. Monetary incentives might be offered to hourly transcriptionists achieving a high rate of production.
The U.S. Department of Labor reports that in 2004 the lowest 10 percent of all medical transcriptionists earned an annual salary of $20,360, and the highest paid 10 percent earned $40,880, annually. The median annual salary was $28,630. Medical transcriptionists who worked in hospitals earned $29,860 annually and those who worked in offices and clinics of medical doctors earned $29,020. Medical transcriptionists who are certified earn higher average salaries than transcriptionists who have not earned certification.
Medical transcriptionists working in a hospital or company setting can expect to receive the usual benefits, including paid vacation, sick days, and health insurance. Tuition reimbursement and 401(k) plans may also be offered. Home-based medical transcriptionists who are employed by a company may be entitled to the same benefits that in-house staff members get. It is important to check with each individual company to be sure. Self-employed medical transcriptionists have to make arrangements for their own health and retirement plans and other benefits.
Most medical transcriptionists work in an office setting, either at their employer’s place of business or in their own homes. They generally sit at desks in front of computers and have transcribers or dictation machines and medical reference books at hand. Home-based workers and sometimes even office workers must invest a substantial amount of money in reference books and equipment on an ongoing basis, to keep up with changes in medical terminology and technology.
Transcriptionists who are not self-employed usually put in a 40-hour week. Some medical transcriptionists working in hospitals are assigned to the second or third shift. Independent contractors, on the other hand, clock their hours when they have work to do. Sometimes this will be part-time or on the weekends or at night. If they are busy enough, some work more hours than in the normal workweek.
Because medical transcriptionists spend such a long time typing at a computer, the risk of repetitive stress injuries is present. Other physical problems may also occur, including eyestrain from staring at a computer screen and back or neck pain from sitting in one position for long periods at a time.
Medical Transcriptionist Career Outlook
As Internet security issues are resolved, its use for receiving dictation and returning transcriptions will likely become more popular. The Internet offers a quick way to communicate and transfer documents, which is useful for medical transcriptionists who work far away from their employers or clients. As voice recognition technology improves and better recognizes complex medical terminology, it, too, will be used more and medical transcriptionists will do less typing.
Even with these technological advances, there will continue to be a need for medical transcriptionists. They will still have to review electronically created documents. And given that people are living longer, they will require more medical tests and procedures, which will all need to be documented and transcribed. The U.S. Department of Labor reports that employment of medical transcriptionists is expected to grow faster than the average through 2014.
For More Information:
- Association for Healthcare Documentation Integrity (AHDI)
- Advance for Health Information Professionals