1. Introduction to MedicalIntroduction to Medical
TranscriptionTranscription
Margaret F. BelloMargaret F. Bello
LecturerLecturer

2. Medical Transcription: OverviewMedical Transcription: Overview
Medical Transcription
(MT) is the act of translating from
oral to written form (on paper or
electronically) the record of a person's
medical history, diagnosis, prognosis,
and outcome in order to document
patient care and facilitate healthcare
services. These documents eventually
become part of patients’ permanent
files.

3. Purposes of MTPurposes of MT
 Ancient cave writings attest to the earliest forms of
healthcare documentation. While the medium
changed from metal plates to clay tablets, to
hieroglyphs on temple walls, to papyrus, to
parchment, to paper, and most recently to electronic
files, the reasons for maintaining records have
always been the same—to record an individual's
health care and the achievements in medical
science.
 Verbal dictation is by far the most common method
for documenting and reporting the results of
examinations and procedures. Physicians generally
use either a cassette based voice dictation system
or a digital voice dictation system to record their
findings. Dictating reports verbally not only allows
physicians to be more thorough in their reporting, it
also saves them a great deal of time.

4. Brief History:Brief History:
 Since 1978, medical transcriptionists have been
represented by a professional organization, the
Association for Healthcare Documentation Integrity
(AHDI), which has developed a competency profile
(COMPRO®) and a model curriculum for
transcription educators, as well as a model job
description. AHDI emphasizes continuing education
for its members, holding an annual conference for
medical transcriptionists, educators, supervisors
and managers, and business owners. There are
over 135 component associations of AHDI, each of
which holds regular educational meetings and
symposia.
 Through the efforts of AHDI, medical
transcriptionists have become recognized as
healthcare professionals with expertise in medical
language.

5. To prepare for this profession,To prepare for this profession,
medical transcriptionists studymedical transcriptionists study
medical language, including Greek and Latin suffixes,
prefixes, and roots biological science, including
anatomy and physiology of all body systems and
various disease processes
 medical science
 medical and surgical procedures, involving
thousands of instruments, supplies, appliances, and
prosthetic devices
 pharmacology
 laboratory values, correlating laboratory test results
with a patient's diagnosis and treatment
 use of medical reference materials and research
techniques

6. MEDICAL TRANSCRIPTIONMEDICAL TRANSCRIPTION
OPERATIONSOPERATIONS
WORK FLOW DIAGRAMWORK FLOW DIAGRAM

7. Background of MT in theBackground of MT in the
PhilippinesPhilippines
 Total MT Firms: 30
 Total MT Firms that are MTIAPI: 27
 Total MT Schools: 9
 MT Professionals: 3,000 employed
 Performance Level: 98 – 99% accuracy rate,
turnaround time of 12 to 24 hours

8. What drives the demand for MT?What drives the demand for MT?
 Demographic data indicates that ourDemographic data indicates that our
population is rapidly aging at thepopulation is rapidly aging at the
same time we are achievingsame time we are achieving
significant improvements in averagesignificant improvements in average
lifespan. These demographiclifespan. These demographic
patterns along with technological andpatterns along with technological and
legal trends suggest that the needlegal trends suggest that the need
for accurate medical transcription willfor accurate medical transcription will
accelerate dramatically in comingaccelerate dramatically in coming
years.years.

9. Salary expectationsSalary expectations
 Annual income for full-time entry-level
transcriptionists typing hospital reports averages
between $20,000 - $35,000 - depending on location
and proficiency.
 More experienced transcriptionists can expect to
make double or even triple that amount on the basis
of production - particularly if they are willing to
develop their own customer base. Unfortunately,
the pay differential between experienced and non-
experienced transcriptionists is not typically as large
in hospital settings where transcriptionists are often
paid by the hour. This is one of the primary reasons
that experienced transcriptionists tend to seek out
positions as independent or sub-contractors where
the opportunity exists to leverage their earnings
potential.

10. The BillingThe Billing
 It turns out that there is a fair degree of flexibility inIt turns out that there is a fair degree of flexibility in
establishing billing parameters. It boils down toestablishing billing parameters. It boils down to
negotiating a rate with a prospective client. Even ifnegotiating a rate with a prospective client. Even if
you determine that you will attempt to adhere to theyou determine that you will attempt to adhere to the
standards provided in the definitions above there isstandards provided in the definitions above there is
still a fair amount of lattitude that derives from thestill a fair amount of lattitude that derives from the
subjectivity inherent in the definitions. For example,subjectivity inherent in the definitions. For example,
assume that you decide to bill based on a 65assume that you decide to bill based on a 65
character line.character line.
For example:For example:
 Assume that for the billing period, your line countAssume that for the billing period, your line count
software calculates a total of 3,500,000 transcribedsoftware calculates a total of 3,500,000 transcribed
gross characters and that your contract defines agross characters and that your contract defines a
billable line as 65 gross characters. Assume that youbillable line as 65 gross characters. Assume that you
have negotiated a price of 14 cents per billable line.have negotiated a price of 14 cents per billable line.
Your bill would be calculated as follows:Your bill would be calculated as follows:
 3,500,000 divided by 65 = 53,846 billable lines3,500,000 divided by 65 = 53,846 billable lines
 53,846 multiplied by .14 = $7,538.0053,846 multiplied by .14 = $7,538.00

11. Medical Transcription: HRMedical Transcription: HR
ProfileProfile
 High School Diploma
 Above-average knowledge of English
punctuation and grammar
 Excellent auditory skills
 Advanced proofreading and editing
skills
 Versatility in use of transcription
equipment and computers
 High degree of trainability
 Customer service orientation

12. Medical Transcription:Medical Transcription:
HR ChallengesHR Challenges
 Availability of trained manpowerAvailability of trained manpower
 Medical professionals seeking jobMedical professionals seeking job
opportunities in other countriesopportunities in other countries
 Training institutions offeringTraining institutions offering
medical transcription coursesmedical transcription courses
 Length of MT training beforeLength of MT training before
becoming productivebecoming productive

13. Medical Transcription:Medical Transcription:
ProgramsPrograms
Organization: Medical Transcription
Industry Association of the
Philippines Inc. (MTIAPI)
 Establishes Policies / Regulations to
MT standards

14. Key terms:Key terms:
 Turnaround time - time need toTurnaround time - time need to
prepare a document forprepare a document for
submissionsubmission
 Accuracy – Exactness. TheAccuracy – Exactness. The
ability of a measurement toability of a measurement to
match the actual value of thematch the actual value of the
quantity being.quantity being.

15. How are Medical TermsHow are Medical Terms
Constructed?Constructed?
 Most medical terms consist of one or more parts. These
word parts may include one or more of the following:
 Root Words
 Prefixes
 Suffixes
 Combining Vowels
 To help you better understand how this works, let's look at
an example.
 Consider the word cholecystectomy. At first glance, this
word seems quite complex. Cholecystectomy, which
means excision (removal) of the gall bladder, is really a
combination of four different word parts. Let's break it
down into its sub parts and see if we can figure out why it
means what it means.
chol - e - cyst - ectomy

16. MT SPECIALITIESMT SPECIALITIES
Immunology
Speech Pathology
ENT - Plastic Surgery
Neurology
Geriatrics
Podiatrics
Pediatrics
Addictive Disorder Treatment
Centers
Biochemical Genetics
Epilepsy Centers
Rehabilitation, etc.
General Medicine
Dermatology
Cardiology
Urology/Nephrology
Orthopedics
OB-GYN
GI/GU
Psychiatry
Ophthalmology
Pulmonology
Endocrinology
Hematology &
Oncology

17. REPORT TYPESREPORT TYPES
 Discharge Summaries
 Consultation
 SOAP Notes
 Operative Notes
 Study reports (MRI/SCAN)
 Urgent Care
 Chart Notes
 Worker Compensation Reports.

18. Example of a SOAP noteExample of a SOAP note
Patient Name: Robert Kryle DOB: 12/31/1961
Record No. K-6112r809
Date: 09/09/99
S—Pt. states that she has always been overweight. She is very frustrated
with trying to diet. Her 20 year class reunion is next year and she would
likt to begin working toward a weight loss goal that is realistic. NKDA,
NKA.
O—WT = 210 lbs HT = 60 “ BW = 115 lbs Chol = 255 BP = 120/75
A—Obese at 183% IBW, hypercholesterolemia
P—Long Term Goal: Change lifestyle habits to lose at least 70 pounds
over a 12 month period. Short Term Goal: Client to begin a 1500 Calorie
diet with walking 20 minutes per day. Instructed Pt on lower fat food
choices and smaller food portions. Client will keep a daily food and mood
record to review next session. Follow-up in one week.
———————————————————————————
- Bob Ridman, CCMA
M. Myer, MD

19. END!END!