In our previous posts, you may have noticed that we talked a lot about technological developments that affect the medical transcription field—electronic medical records, home office equipment, and speech recognition software. All of these things have and will continue to change and evolve. There is at least one thing, however, that remains the same. Even with these advances in technology, it is still the responsibility of the medical transcriptionist to ensure accurate transcription. Why? Because, as the previous blogs have noted, analyzing context, critical thinking, decision making and, therefore, researching are all beyond the abilities and boundaries of a machine.
Several years ago, an MT would lug out a 10-pound medical terminology dictionary and thumb through it in order to look up unfamiliar terms. Today we don’t have to deal with a clumsy, over-sized book on our desk, but we still have to investigate unfamiliar terms and other areas of possible inaccuracy. While we don’t want to get bogged down heavily researching every report, it’s important for the transcriptionist to know both when and how to research, without investing a lot of time yielding fruitless results. Becoming this type of intuitive researcher doesn’t happen overnight, though!
When you know a word is incorrectly used or you can’t quite understand the drug dosage that is dictated, researching is the obvious thing to do. Instances like these are the starting point for becoming an intuitive researcher. When faced with these situations, you quickly learn to use a dictionary site to double-check the meaning of a word and to tap into a favorite pharmacology resource for correct dosing information. As you gain more experience learning medical terminology, you will start to expand your researching methods, checking sounds-like sites in case the dictator was simply mispronouncing the word, and locating manufacturers’ sites to find accurate information on the latest medications.
Then there are times when researching may not seem like the best—or should I say, “easiest”—approach. Especially as a new student, you be bombarded with terminology you are likely seeing and hearing for the first time in your life. Just about every sentence in a medical report might seem like a complicated sentence that lacks understandability. You may be very tempted to shrug it off as part of the learning process and just plow ahead, transcribing words that don’t necessarily make sense just to avoid receiving the dreaded “significant omission.” After all, you do just want to hurry up and start working already!
Don’t give in to the temptation of ignoring report context that you do not understand! While you will likely never fully understand every single phrase in every report you transcribe, some reasonable action on your part right now, while working your way through your medical transcription or editing program, will pay off generously in the future. Take the example mentioned above, in which you, a student, are faced with a report that has a lot of unfamiliar terminology. If you invest the time and effort right now into looking for diagrams (Google Images is often a great place for this) that will help with understanding the referenced anatomy and for sample reports (http://www.mtsamples.com is just one of several sites to offer samples) to help fill in some of the blanks—and then you save these sites to your favorites in an organized manner and perhaps add the unfamiliar terminology to your word list—the next time you come across a report involving cardiac catheterization, you will have already done the leg work in researching and will know exactly where to look.
As you have repeated exposure to common procedures, anatomical structures, surgical equipment, and drug dosages, you’ll find that your gut feeling starts to kick in. Even though you may not know exactly what the usual dosage is for Synthroid, you will find a little red flag appears in your mind when you hear a dictator say, “Synthroid 50 mg per day,” being relatively certain that a dose of Synthroid 50 should be in mcg and not mg. You will then automatically proceed to your favorite drug resource to verify your suspicion, flag the report for clarification, and then continue on with transcribing the report, all in a matter of seconds!
Though researching is certainly a skill that needs to be developed, over time you’ll find that it becomes second nature to know when and how to research. We are, after all, intelligent creatures who go far beyond the boundaries of a machine.