Practical And General Rules To Remember When Transcribing

There are a lot of rules a medical transcriptionist must abide with but to be practical, I have listed 6 general rules that summarizes all of them for readers to understand and not get bored with reading.

Here are the 6 rules/tips you should always remember when transcribing:

 1. Always assume that doctors would always spell wrong. Don’t assume everything you heard is correct. They are the best healthcare practicioners but are often bad spellers. Don't ever trust their spelling when they spell it out for you. It might be spelled wrong. If you're not sure of the spelling given, search for it or leave it blank. Accuracy should always be the #1 concern for all medical reports.

2. Often, physicians will not pronounce the entire word. To quicken the dictation, they will most likely use abbreviations and acronyms such as CABG (often heard as "cabbage") and PERR (usually heard as "per"). Look it up first. Don't transcribe (yet) those words if you're not sure it's consistent with the report.

3. Some doctors inlcude punctuations when dictating such as "comma" and "colon" after every pause. When transcribing, do not include these in the report as words in the sentences. 

4. Remember "Verbatim." Transcribe what you hear - word for word. Except for the two I have mentioned earlier.

5. If you can't transcribe the word, better leave it blank than guessing. If you can't understand the word, it's better to leave it out blank than putting a word that you are uncertain of. Blanks are always better than sound alikes. It’s better to admit your defeat than to acting smart. 

6. Keep the patient's record private. Always keep it to yourself. As you know, it is strictly prohibited to spread/disseminate any personal information that would compromise the patient's privacy. So don't talk about it. Even if it's contagious.


See Me We Fly said...

I wanted to become a medical transcriptionist but it looks very difficult to transcribe things from doctors.

MT Central said...

There are no difficult dictations when you are properly trained in medical transcription. Don't be afraid to try medical transcription. Its just a matter of time and persistance that you will get the hang of it, just like the other starting medical transcriptionists. They too find medical transcription difficult, but as soon as they learned the trade, it all became somewhat easier for them to handle.