Medical transcriptionists listen to dictated recordings made by physicians and other healthcare 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 clairty. The documents they produce include discharge summaries, history and physical examination reports, operative reports, consulation reports, autopsy reports, diagnostic imaging studies, progress notes, and referral letters.
To understand and accurately transcribe dictated reports into a format that is clear and comprehensible for the reader, medical transcriptionists must understand medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and tratment assessments. They must also be able to translate medical jargon and abbreviations into their expanded forms.
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.
Many medical transcriptionists telecommute from home-based offices as employees or subcontractors for hospitals and transcription services, or as self-employed independent contractors.