Learn how to transcribe the medical reports most often used in healthcare today, and discover how to get started and advance as a medical transcriptionist.
In this course, you will learn how to transcribe the most common medical reports used in both inpatient and outpatient settings. This knowledge will help prepare you to work almost anywhere in the medical field—doctors' offices, clinics, public health facilities, and hospitals. With this foundation, you will be set to advance your education so you can work as a subcontractor for a company that outsources transcription, or you can eventually even take on your own clients—all from the comfort of your own home.
You will go through each of the nine main report types—their formatting requirements, the components of each one, and how they are used in the clinical setting. Every lesson will include a grammar review, pointing out important elements that will make your reports perfect. You will also gain important clinical knowledge of major disease processes that are essential to enhance your skill as a medical documentation specialist.
Along the way, you will download a free transcriber to listen to dictation and produce reports. These hands-on exercises will give you the practice you will need to determine if this field is for you. You will also go through your current options and in the future by developing the skills of a medical transcriptionist. By the end of this course, you will know the basic report types, have clinical knowledge of major diseases, be able to correct grammar from dictated reports on the fly, and know the next steps you will need to take!
- This course can be taken on either a PC or Mac.
- PC: Windows XP or later.
- Mac: OS X Snow Leopard 10.6 or later.
- Browser: The latest version of Google Chrome or Mozilla Firefox are preferred. Microsoft Edge and Safari are also compatible.
- Adobe Flash Player. Click here to download the Flash Player.
- Adobe Acrobat Reader. Click here to download the Acrobat Reader.
- Software must be installed and fully operational before the course begins.
- Email capabilities and access to a personal email account.
There are no prerequisites for this course. However, it is recommended that you have prior knowledge of medical terminology and touch-typing before enrolling in this course.
Instructional Material Requirements:
The instructional materials required for this course are included in enrollment and will be available online.Learn how to transcribe the most common medical reports used in both inpatient and outpatient settings. This course contains grammar review, as well as important clinical knowledge of major disease processes that are essential to enhancing your skills as a medical documentation specialist.
Introduction to Medical Transcription
This first lesson looks at the history of medical transcription as a career. You will find out how the field has evolved into its modern form, and you will explore the various skills and aptitudes that you will need to succeed as a professional medical transcriptionist. You will examine the type of work MTs produce, where you might work, and what might be in store for those working in this career field.
Tools of the Trade
This lesson focuses on the tools of the trade. You will review a few of the reference books and examine the types of websites that MTs use for research. Then, you will learn about the hardware and software that MTs use on the job. By the end of this lesson, you will be sitting at your computer, listening to a real medical dictation audio file and looking at the Express Scribe software on your screen. As you listen to the medical report, you will practice starting, pausing, and rewinding the audio as you tap away on the keyboard.
Understanding Medical Records
There are nine report types that medical professionals use most often in both hospitals and clinics. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, you might need a refresher. You will finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then you will practice transcribing a medical letter and a pathology report.
This lesson goes over how to listen most effectively, discussing the difference between hearing and active listening. You will also touch on many of the issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. You will learn how to use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Next, you will learn about radiology reports and finish up by practicing transcribing one.
Grammar, Sentence Structure, and Punctuation
This lesson covers some subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better MT. Then, in your Practice Corner, you will learn about SOAP notes and then turn your attention to infectious diseases and medications. You will also have the chance to transcribe a SOAP note and a radiology report in the assignment that accompanies the lesson.
This lesson explores writing and talks about style from the MT's perspective. When you're transcribing, you must follow editorial directions in spelling, capitalization, and typographical display. And it's those directions that are the style MTs need to be concerned about. You may be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercased? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? Finally, in your Practice Corner, you will focus on the H&P report and practice transcribing one.
Medical Terminology and Spelling
No matter what you transcribe, one thing is a given: Medical terminology will be a huge part of it. One thing to remember is that dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like cystitome and cystotome. If you have a good understanding of medical terminology, you can pinpoint the correct word to make sure your transcription is accurate. Then, in your Practice Corner, you will review the basic nature of heart disease and its treatment.
Report Formatting and Word Processing
A critical component of the MT's work is the way you put your reports together. This lesson focuses on breaking your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. You will also take a closer look at ways to make your work easier with word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient MT! This lesson's Practice Corner focuses on surgical reports. Surgical terminology is important to know, and it's also fascinating to take an inside look at what goes on in the operating room.
Checking Your Work
Another essential step in transcription is editing and proofreading your work. This lesson starts off with editing do's and don'ts, as well as what to look for when you're proofreading. In your Practice Corner, you will be covering a disease process that has, in some way, touched virtually everyone: cancer. Once you have an overview of cancer, you will work on the consultation report. Physicians often ask specialists to further evaluate their patients, especially cancer patients. So, this is a common report that you're likely to transcribe regularly. The assignment for this lesson includes a consult report to transcribe, and you will also get to practice proofreading.
Classification Systems, and Discharge and Death Summaries
This will be a completely clinical lesson. You will learn about classification systems and their transcription foibles. And now that you have the bones of grammar and style down, you will learn about real bones. Finally, in your Practice Corner, you will learn about discharge and death summaries. They are very similar reports, but this lesson explains the subtle differences.
Infections, Blood, and Cells
This lesson will be similar to the last in that it covers lots of clinical issues. It won't all be clinical, however. In your Practice Corner, you will see how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you will ever come across. And, of course, you will have the chance to transcribe an autopsy report in the assignment!
The Nuts and Bolts of Working as an MT
By now you have the tools and the knowledge you need to dip your toe into the waters of medical transcription, but there are still some big questions to answer. This lesson will help you learn how to manage your workload, discover all of the different ways you can work as a medical transcriptionist, and give you tips on finding a job in the field. You will also learn about further training options and what it takes to begin your career in medical transcription.
Jennifer Della'Zanna has more than 20 years of experience in the healthcare industry, having worked as a medical transcriptionist, practice administrator, biller, and coding specialist. She writes courses and study guides on the use of technology in health care and regularly contributes to publications about health issues. Della'Zanna is a member of the American Academy of Professional Coders and the Association for Healthcare Documentation Integrity. She holds a Bachelor of Arts from Albright College.