Medical transcriptionists listen to dictated recordings made by physicians and other health care professionals and transcribe them into medical reports, correspondence, and other administrative material. They generally listen to recordings on a headset, using a foot pedal to pause the recording when necessary, and key the text into a personal computer or word processor, editing as necessary for grammar and clarity. The documents they produce include discharge summaries, history and physical examination reports, operative reports, consultation reports, autopsy reports, diagnostic imaging studies, progress notes, and referral letters. Medical transcriptionists return transcribed documents to the physicians or other health care professionals who dictated them for review and signature, or correction. These documents eventually become part of patients’ permanent files.

Employers prefer to hire transcriptions who have completed postsecondary training in medical transcription, offered by vocational schools, community colleges, and distance-learning programs. Formal training that includes coursework in anatomy, medical terminology, legal issues relating to health care documentation, and English grammar and punctuation is highly recommended. Employers require applicants to take pre-employment tests.

To understand and accurately transcribe dictated reports into a format that is clear and comprehensible for the reader, medical transcriptions must understand medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. They also must be able to translate medical jargon and abbreviations into their expanded forms. To help identify terms appropriately, transcriptionists refer to standard medical reference materials—both printed and electronic; some of these are available over the internet. Medical transcriptionists must comply with specific standards that apply to the style of medical records, in addition to the legal and ethical requirements involved with keeping patient information confidential.

Experienced transcriptionists spot mistakes or inconsistencies in a medical 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 health care providers transmit dictation to medical 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 utilizes speech recognition technology, which electronically translates sound into text and creates drafts of reports. Reports are then formatted; edited for mistakes in translation, punctuation, or grammar; and checked for consistency and any possible medical errors. Use of speech recognition technology will become more widespread as the technology becomes more sophisticated.

Many medical transcriptionists telecommute from home-based offices as employees or subcontractors for hospitals and transcription services or as self-employed, independent contractors. Self-employed medical transcriptionists are more likely to work irregular hours —including part time, evenings, weekends, or on call at any time.

Employment of medical transcriptionists is projected to grow faster than the average for all occupations through 2014. Demand for medical transcription services will be spurred by a growing and aging population. A high level of demand for transcription services also will be sustained by the continued need for electronic documentation that can easily be shared among providers, third-party payers, regulators, consumers, and health information systems. Growing numbers of medical transcriptionists will be needed to amend patients’ records, edit documents from speech recognition systems, and identify discrepancies in medical reports.