When a patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past problems. The doctor may do a physical examination, conduct various laboratory or diagnostic studies, make a diagnosis, and then decides on a plan of treatment and discusses it with the patient. After the patient leaves, the doctor uses a voice recording device to record the information about the interaction with the patient. This information is then sent to a medical transcriptionist and received as a voice file, who then listens to the voice file and transcribes it into the required format to make a medical record which is also a legal document that may be subpoenaed. The next time the patient visits the doctor, the doctor can call for the medical record. The doctor may also refill medications after seeing only the medical record.
It is important to have a properly written, edited and reviewed medical transcription document. If a medical transcriptionist accidentally typed a wrong medication or wrong diagnosis, the patient's life would be put at risk if the doctor did not review the document for its consistency. Both the doctor and the medical transcriptionist play an important role to make sure the transcribed dictation is correct and accurate. The doctor should speak slowly and concisely, especially when dictating medications or diseases, and the medical transcriptionist must possess hearing acuity, medical knowledge, and good reading comprehension.
Doctors often do not review their transcribed reports for accuracy. Add to this the fact that most doctors do not speak clearly or concisely, let alone slowly. Medical doctors are rarely accurate spellers. It is the job of the transcriptionist to look up the correct spelling of complex medical terms. Medicine in America is constantly changing. New equipment, new medical devices, and new medications come on the market on a daily basis. Medical transcriptionists need to be creative and tenacious researchers in order to search for and find these new words.