Medical Transcription and the Accuracy of Medical Documents

The technique of medical writing is different from other writing as seen in literature or while writing essays or articles for publications. How is it different? Some of the typical features seen in medical writing:

• Has lots of abbreviations
• Have brief forms
• Shortcut language /word coinage

Medical transcriptionists do not have to bring out a polished document, or rewriting it several times like done by other writers, especially as they always have to work at a fast pace with a high level of accuracy. It is not expected of them to do any creative form of writing at all. However it is essential that a medical transcription should produce a clean and accurate transcription of the source document /dictation.

Adherence to prescribed or suggested stylistic guidelines as prescribed by the agency is very important. These can be vendor specific instructions with regards to editing, punctuation, or the grammar. However in the absence of any specific guide lines transcriptionists can follow the general rules as followed by other transcription professionals.

Challenges in transcribing mainly are seen because dictations are never ever close to being perfect. While dictating, doctors may even make mistaken or contradicting statements due to slip of tongue. Here it is up to the transcriptionist to be alert to all such issues and correct all such dictation mistakes done by the physician.

A sound knowledge of all medical terms and by listening and handling a wide variety of such dictations make a transcriptionist becomes experienced to face all types of audio files. But if a transcriptionist can keep listening to any particular physician on a regular basis and works on the same voice files then he/she can get quite used to a physican's personal style of dictation and can quickly produce a very accurate transcript.

The secret of the art of medical transcription is not in being aggressive but to be as subtle and careful as possible. Also it is very essential to have an attitude to impress and always get a favorable response from the dictator. Having a keen sense of awareness/ alertness to the possible mistakes in dictations along with good listening skills will go a long way in becoming a successful MT professional. However while editing a dictation one must also know where to draw the line and must be careful never to overdo it.

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