The Medical Transcriptionist Is A Vital Link In The Delivery Of Patient Healthcare

The Medical Transcriptionist is a Vital Link in the Delivery of Patient Healthcare

The hospital admission sheet or patient demographic face sheet contains:

• Patient's address
• Next of kin
• Birthplace
• Social security number
• Occupation
• Sex
• Marital status
• Ethnic origin
• Religious preference
• Admitting diagnosis
• Financial entries that include patient's employer, job title, address of company, insurance company, person responsible for emergency notification and payments, type of coverage, insurance identification number, type of payment plan

The hospital is required by federal law to collect this minimum amount of information, which is recorded on the admission face sheet and available in some format to the Medical Transcriptionist to assist in patient identification. The Medical Transcriptionist's role here is to transcribe this information with complete accuracy in a timely manner.

The admissions department is also responsible for obtaining a consent form which includes:

• Patient's consent for treatment
• Outline of patient's responsibilities including billing
• The assurance that confidentiality will be protected

Other informed consents for surgery, procedures, invasive diagnostic tests, transfer, etc. will be obtained as appropriate.

Medical entries of the patient's healthcare record include:

• Physician orders
• Diagnostic tests
• Nursing entries
• Physician entries
• Therapists' entries
• Ancillary personnel entries

Emergency record:

Patients evaluated and treated in the Emergency Department receive a condensed version of the inpatient healthcare record that includes:

• Demographic information
• Nursing assessment
• Physician's evaluation
• Treatment
• Conclusions

The Medical Transcriptionist may need to transcribe a dictated note with a comprehensive visit that might include:

• Diagnostic test results
• Consents
• Instructions

Physician's office healthcare records are maintained in the physician's office and may include:

• Many, but not all, of the same records and forms contained in the hospital healthcare record
• Initial history and physical exam
• Office visit notes
• Progress notes
• Diagnostic test results
• Copies of acute hospitalization reports
• Letters to insurance companies
• Consultation letters

The Medical Transcriptionists plays a vital role in the delivery of healthcare while accurately transcribing timely data entries that communicate illness and wellness information throughout the healthcare system.

Medical transcription requires physical skills of coordination of your eyes, ears, fingers, and foot (if you use a foot pedal). You should be an accomplished typist having a copy typing speed of at least 45 words per minute before attempting to transcribe. You should also expect your transcription to be slow and halting in the beginning as medical transcription does require somewhat different than copy typing.

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© 2007 Connie Limon All Rights Reserved