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MEDICAL TRANSCRIPTION SERVICES

When the patient visits a doctor, the latter spends time with the former discussing his medical problems, including history and/or problems. The doctor performs a physical examination and may request various laboratory or diagnostic studies; will make a diagnosis or differential diagnoses, then decides on a plan of treatment for the patient, which is discussed and explained to the patient, with instructions provided. After the patient leaves the office, the doctor uses a voice-recording device to record the information about the patient encounter. This information may be recorded into a hand-held cassette recorder or into a regular telephone, dialed into a central server located in the hospital or transcription service office, which will 'hold' the report for the transcriptionist. This report is then accessed by a medical transcriptionist, it is clearly received as a voice file or cassette recording, who then listens to the dictation and transcribes it into the required format for the medical record, and of which this medical record is considered a legal document

There are many companies providing medical transcription services, but they are not providing guarantee of work.

Duties and responsibilities:

  1. Listen to the recorded dictation of a doctor or other healthcare professional
  2. Transcribe and interpret the dictation into diagnostic test results, operative reports, referral letters, and other documents
  3. Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and has a consistent style
  4. Translate medical abbreviations and jargon into the appropriate long form
  5. Identify inconsistencies, errors, and missing information within a report that could compromise patient care
  6. Follow up with the healthcare provider to ensure the accuracy of the reports
  7. Submit health records for physicians to approve
  8. Follow patient confidentiality guidelines and legal documentation requirements
  9. Enter medical reports into electronic health records systems
  10. Perform quality improvement audits