What Does A Medical Transcriptionist Do?

Medical transcription is like nothing else you'll ever experience. Doctors see patients in hospitals, clinics and physicians' offices and dictate important information about the patient's history, physical examination, diseases, procedures, laboratory tests and diagnoses. They talk in technical terms and often so quickly that you must know approximately what they are supposed to say or you won't be able to understand it when you hear it!

New students often think that the "dictation" doctors do is like some executive dictating a letter to a secretary, in which he/she specifies every line break, every paragraph, every punctuation mark, and most of the spelling. This is absolutely NOT how doctors dictate. They expect the medical transcriptionist to do the formatting, the spelling, and to convert that dictated material from the doctor's shorthand medical slang to formal medical language.

Doctors often say things in their dictation that they never intend to be transcribed. They say, "Oh, no, start over," "Go back and change that," and make all sorts of chitchat. They tell the transcriptionist jokes, relate cute stories, and they sing! They have conversations with people around them and often do this WHILE doing the actual dictation.

Example of something a medical transcriptionist might hear:

"The patient is a 32-year-old put him in room 2 white male who presented with a yeah, start an IV chief complaint of rats I can't find it what was this guy's problem when he got here? Never mind belly pain (rattle of x-ray film) ...okay, she can go; this is clear."

They also often begin and end by saying hello, goodbye, thank you, and have a nice holiday. They don't intend for this to be transcribed. The job of the medical transcriptionist is to figure out what is supposed to be part of the report and what is not. We are not robots who simply repeat everything we hear. We use judgement in deciding what to include and what not to include. Even if you are asked to do "verbatim" transcription, they NEVER expect you to type every noise the dictator makes. We don't transcribe noises; we transcribe and interpret meaning. We do that without changing the style of the physician's dictation and without ever changing the medical meaning. The end result is that the report says exactly what the doctor wants it to say.

That's what medical transcriptionists do.