Certificate in Exploring a Career in Medical Transcription Online Course

In this first lesson, we'll look at the history of medical transcription as a career. You'll find out how the field has evolved into its modern form, and you'll explore the various skills and aptitudes that you'll need to succeed as a professional medical transcriptionist. You'll examine the type of work MTs produce, and we'll take a look at the MT's job today, where you might work, and what might be in store in the future for those working in this career field.

Tools of the Trade

We'll start today by discussing the MT's tools of the trade. We'll review a few of the reference books and discuss the types of Web sites that MTs use for research. Then we'll take a look at the hardware and software that today's MTs use on the job. I'll talk you through downloading the free software we'll use in this course, and then we'll go through a quick tour on how to use it. By the end of this lesson, you'll be sitting at your computer, listening to a real medical dictation audio file and looking at the Express Scribe software on your screen. As you listen to the medical report, you'll practice starting, pausing, and rewinding the audio as you tap away on the keyboard.

There are nine report types that medical professionals use most often in both hospitals and clinics. So in this lesson we'll go over a variety of examples of real medical reports. We'll also do a quick review of medical correspondence. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, you might need a refresher. We'll finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then you'll practice transcribing a medical letter and a pathology report.

Listening Carefully

We'll spend this lesson going over how to listen most effectively, discussing the difference between hearing and active listening. We'll also touch on many of the issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. Then we'll discuss how you can use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Then we'll talk a bit about the radiology department and radiology reports, and we'll finish up by practicing transcribing one in today's assignment.

Today we're going to talk about some subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But I promise this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better MT. Then, in our Practice Corner, we'll talk a little more about SOAP notes and then turn our attention to infectious diseases and medications. You'll also have the chance to transcribe a SOAP note and a radiology report in the assignment that accompanies the lesson.

Style

We'll continue our examination of writing in this lesson by talking about style from the MT's perspective. When you're transcribing, you must follow editorial directions in spelling, capitalization, and typographical display. And it's those directions that are the style MTs need to be concerned about. I think you'll be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercased? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? These are the issues we'll be covering in this lesson. Finally, in our Practice Corner, we'll focus on the H&P report, and you'll have the chance to practice transcribing one.

No matter what you transcribe, one thing is a given: Medical terminology will be a huge part of it. That's what we'll be focusing on today. One thing to remember is that dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like cystitome and cystotome. If you have a good understanding of medical terminology, you can pinpoint the correct word to make sure your transcription is accurate. Then, in our Practice Corner, I'll review the basic nature of heart disease and its treatment. We'll also take a close look at another common disease: diabetes.

Report Formatting and Word Processing

A critical component of the MT's work is the way you put your reports together. So in this lesson, we'll talk about how to break up your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. We'll also take a closer look at ways you can make your work easier by using word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient MT! In the Practice Corner, we'll focus on surgical reports. Surgical terminology is important to know, and it's also fascinating to take an inside look at what goes on in the operating room. The assignment for this lesson will include a surgical report to help you put to work all the new knowledge you've gained.

Another essential step in transcription is editing and proofreading your work. And that's what we'll concentrate on today. I'll start off by sharing some editing do's and don'ts as well as what to look for when you're proofreading. In our Practice Corner, we'll be covering a disease process that has, in some way, touched virtually everyone: cancer. Once you have an overview of cancer, we'll work on the consultation report. Physicians often ask specialists to further evaluate their patients, especially cancer patients. So this is a common report that you're likely to transcribe regularly. The assignment for this lesson includes a consult report to transcribe, and you'll also get to practice proofreading.

Classification Systems, and Discharge and Death Summaries

So far we've focused on the mechanical elements of medical transcription. But there is still a lot you need to know about clinical issues. So this will be a completely clinical lesson. We'll talk about classification systems and their transcription foibles. And now that you have the bones of grammar and style down, we're going to talk about some real bones. We'll begin by discussing information on fractures and spine levels. Finally, in our Practice Corner, we'll discuss discharge and death summaries. They are very similar reports, but we'll take a look at some of their subtle differences.

Infections, Blood, and Cells

This lesson will be similar to the last in that it covers lots of clinical issues. It won't all be clinical, however. There are a few miscellaneous things that I want to make sure I share with you. They don't really fit into neat categories, so I've put them all here. Once we finish with these miscellaneous items, we'll jump back into some clinical issues. We'll be talking specifically about infections. Then we'll turn our attention to smaller parts of the body—cells and blood. Then, in our Practice Corner, you'll see how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you'll ever come across. And, of course, you'll have the chance to transcribe an autopsy report in the assignment!

The Nuts and Bolts of Working as an MT

By now you have the tools and the knowledge you need to dip your toe into the waters of medical transcription. But we still have a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist? And do you need more training? Today we'll discuss all the different ways you can work—everything from being an independent contractor all the way up to consultant work. We'll talk about additional training as well. Then we'll take a peek at some of the events on the horizon, and you'll see why this is an exciting time to enter the transcription field. For our final Practice Corner, we'll look at the Health Story Project. It's an initiative to develop standards for integrating narrative reports (like the ones you've been transcribing) into the electronic medical record in a meaningful way—giving them the ability to be searched and to extrapolate data like we have never been able to do before.