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Medical Transcription Demo - Page 8 |
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Transcriptionists paid by the line, word, byte, page, or some other measure of their production perform in a production-oriented, fast-paced environment. The MT usually produces a final copy the first time, as there is little to no opportunity for draft copies. Transcriptionists paid by the hour often earn incentive pay on top of their hourly salary, so speed is important for them, too. Every facility will have styles for you to learn and use. Learning the Hillcrest style will prepare you for the occasional employer/client who asks that you use your own style. In your career as an MT you may see many styles in which a History and Physical or other medical report may be formatted, none of which is wrong. Accuracy, legibility, and consistency are always important. Get everything the originator dictates to you transcribed, making sure that it is readable, that the sentence structure makes sense. Be consistent in your format, style, and punctuation. Change NOTHING that could affect the medical content. On the job, dictation errors, as far as grammar, verb tense, spelling, gender mix-ups, repeating words or lines, and/or left/right mix-ups can be addressed by the MT. You may need to check with a supervisor for some of this; however, as you become more experienced and get to know your physicians, they may allow you to make more sophisticated editing changes. This will depend on where and how you work. It is strictly the dictator's responsibility to change medical meaning. Do not be surprised if you have an employer/client who insists their work be transcribed verbatim. The composition of the dictated report is THEIR responsibility, not yours. They are legally responsible for the information. All reports must be authenticated (signed) by the dictating healthcare professional, usually a physician. There are electronic signatures and even rubber stamps in addition to handwritten signatures. An electronic signature means the computer automatically signs the report, sometimes with a statement that reads, "dictated but not read" or "signed but not read." A rubber stamp is just what it sounds like-the physician's name carved out on a stamp. With the use of an inked pad, the signature is stamped onto the report in the appropriate place(s). There are both controversy and legal issues that surround these types of signatures, and some states have laws that prevent their use. |