To understand and accurately transcribe dictated reports, medical/legal transcriptionists must understand medical/legal terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. They also must be able to translate medical/legal jargon and abbreviations into their expanded forms. To help identify terms appropriately, transcriptionists refer to standard medical/legal reference materials—both printed and electronic; some of these are available over the Internet. Medical/Legal transcriptionists must comply with specific standards that apply to the style of medical/legal records and to the legal and ethical requirements for keeping patient information confidential.
Experienced transcriptionists spot mistakes or inconsistencies in a medical/legal report and check to correct the information. Their ability to understand and correctly transcribe patient assessments and treatments reduces the chance of patients receiving ineffective or even harmful treatments and ensures high-quality patient care.
Currently, most healthcare providers transmit dictation to medical/legal transcriptionists using either digital or analog dictating equipment. The Internet has grown to be a popular mode for transmitting documentation. Many transcriptionists receive dictation over the Internet and are able to quickly return transcribed documents to clients for approval. Another increasingly popular method uses speech recognition technology, which electronically translates sound into text and creates drafts of reports. Transcriptionists then format the reports; edit them for mistakes in translation, punctuation, or grammar; and check for consistency and any wording that doesn’t make sense medically. Transcriptionists working in specialties, such as radiology or pathology, with standardized terminology are more likely to use speech recognition technology. However, speech recognition technology will become more widespread in all specialties as the technology becomes more sophisticated, that is, better able to recognize and more accurately transcribe diverse modes of speech.