Medical Transcription Rules

Obeying the Rules of Medical Transcription

Medical transcription is an important and permanent aspect of your medical history and charts. Doctors dictate every aspect of your visit and medial transcribers listen to and transcribe this information onto a document that goes in your record. If you are considering medical transcription as a career, there are a number of rules ranging from grammar to legal to learn.

Education

According to the AAMT--the American Association of Medical Transcription--you must obtain training and graduate from a medical transcription school to begin your career as a medical transcriptionist. You must be proficient in medical terminology and anatomy. You will also be expected to know various lab terminologies and medical abbreviations and use the AAMT Book of Style. You are also expected to obtain continuing education because medical terminology is always changing. The AAMT is now called the Association for Healthcare Documentation Integrity (AHDI).

Grammar

According to meditec.com, there are a number of spacing requirements for certain documents. There are requirements for comma use, for when to spell out numerals, and for how to type measurements and when capitalization is required. You will be required to learn what words to hyphenate, and when to use abbreviations and when to spell out a word.

Patient Confidentiality

Before you transcribe your first document you will sign a confidentiality agreement. According to the American Association of Medical Transcription, a medical transcriptionist must work from a secure location. This can be a hospital, office or home. If you are working at home you must verify that the computer screen is facing an area unseen by traffic flow in your home. The transcriptionist must never keep a copy of a transcript. If the transcript is in hard-copy form and faxed to the medical provider, the transcriptionist must subsequently shred that document. You must work on a secure computer system and if documents are sent via email they must be encrypted. After you send the documents you must immediately purge them from your computer.

Computer Repair

If you have someone repair your computer you will need to remove all undelivered patient-history information from your hard drive. You will also need to make a note of who performed the repairs.

Don't Assume

While you are working as a medical transcriptionist you are never allowed to make assumptions. If you do not clearly understand what the doctor is saying on the recording, leave a blank. Those who guess can wind up stating that the patient was diagnosed with the wrong disease, or given the wrong medicine or treatment.

Considerations

There are work-at-home sites that promise to deliver quick medical transcription training. Reputable schools will have a connection to the AAMT, which is now called AHDI, the Association for Healthcare Documentation Integrity, and will teach all the rules and regulations.

References

• Meditec Grammar for Medical Transcription
• AAMT Confidentiality and Security

Resources

• AAMT