Explore a Career in Medical Transcription/Healthcare Documentation

We'll continue our writing examination in this lesson by discussing style from the HDS perspective. Whether transcribing or editing a document produced by voice recognition, you must follow editorial directions in spelling, capitalization, and typographical display. Those directions are the style HDSs must be concerned about. You'll be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercase? 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 will cover in this lesson. Finally, we'll focus on the H&P report, and you'll have the chance to practice transcribing one.

No matter what you transcribe or edit, you can be sure that medical terminology will be a huge part of it. That's what we'll be focusing on today. 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 anuresis and enuresis. If you understand medical terminology well, you can pinpoint the correct word to ensure your transcription is accurate. Then, we will review the basic nature of heart disease and its treatment. We'll also take a close look at another common disease: diabetes.

A critical component of the HDS's work is how you put your reports together. So, 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 look closer 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 HDS! We will also focus on surgical reports. Surgical terminology is important to know, and it's also fascinating to take a 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 healthcare documentation is editing and proofreading your work; that's what we'll concentrate on today. We will start by sharing some editing do's and don'ts and what to look for when proofreading. We will cover a disease process that has affected virtually everyone in some way: cancer. Once you have an overview of cancer, we'll work on the consultation report. Physicians often ask specialists to evaluate their patients, especially cancer patients, further. So, this is a common report you'll likely transcribe regularly. The lesson assignment includes a consult report to transcribe, and you'll also get to practice proofreading.

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 an entirely clinical lesson. We'll talk about classification systems and their transcription foibles. Plus, now that you have the bones of grammar and style down, we'll talk about some real bones. We'll begin by discussing fractures and spine levels. Finally, we'll discuss discharge and death summaries. They are very similar reports, but we'll examine some subtle differences.

This lesson will be similar to the last in that it covers many clinical issues. It won't all be clinical, however. There are a few miscellaneous things to cover. They don't fit into neat categories, so they are all put here. Once we finish with these miscellaneous items, we'll jump back into some clinical issues, talking specifically about infections. Then, we'll focus on smaller components of the body: cells and blood. You'll notice how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you'll come across. Of course, you'll also have the chance to transcribe an autopsy report in the assignment!

By now, you have the tools and the knowledge you need to dip your toe into the waters of healthcare documentation. But there are still 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? This lesson will discuss the various 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, you'll take a peek at why this is an exciting time to enter the medical transcription field. You will look at some details about working in related fields, such as document integrity specialist, EHR specialist, and scribe.