CHAPTER 1

CHAPTER 1
INTRODUCTION TO MEDICAL TRANSCRIPTION
WHAT IS MEDICAL TRANSCRIPTION

Medical transcription, also known as MT, is an allied health profession dealing
with the process of transcribing voice-recorded medical reports that are
dictated by physicians, nurses and other healthcare practitioners. Medical
reports can be voice files, notes taken during a lecture, or other spoken
material. These are dictated over the phone or uploaded digitally via the
Internet or through smart phone apps.

WHAT DO MEDICAL TRANSCRIPTIONIST DO

Doctors, nurse practitioners, and other healthcare providers dictate their
confidential notes about each visit. Transcriptionists take these notes and
transcribe them into a comprehensive record of the visit.
They use a template based on the type of practice, with most specialties having
different requirements. Sometimes they receive files that are unedited speech-to-
text translations. They then edit and format these notes and turn them into a
finished document.

SKILLS REQUIRED FOR A MEDICAL TRANSCRIPTION JOB

• Typing speed
• Typing accuracy
• Medical knowledge
• Grammar, spelling and punctuation accuracy.
• Active listening
• Attention to details
• Time management skills
• Critical thinking skills
• Computer skills

LAWS THAT A MT SHOULD KNOW

There are some of the Health Care Associated Laws of US, which a MT need to
be mandatorily known and compliant with.

HIPAA COMPLIANCE: Compliance with HIPAA regulations is a process that
business associates and covered entities follow to protect and secure
Protected Health Information (PHI) as prescribed by the Health Insurance
Portability and Accountability Act. That's legalese for “keep people's
healthcare data private.” Three rules for protecting patient health
information are The Privacy Rule, The Security Rule, The Breach Notification
Rule.

THE PRIVACY RULE: The HIPAA Privacy Rule establishes national standards to
protect individuals' medical records and other individually identifiable health
information (collectively defined as “protected health information”).

THE SECURITY RULE: The HIPAA Security Rule establishes national standards
to protect individuals' electronic personal health information that is created,
received, used, or maintained by a covered entity.

THE BREACH NOTIFICATION RULE: If a breach affects 500 or more individuals,
covered entities must notify the Secretary without unreasonable delay and in
no case later than 60 days following a breach. If, however, a breach affects
fewer than 500 individuals, the covered entity may notify the Secretary of such
breaches on an annual basis.

COVERED ENTITIES: Covered entities under HIPAA include health plans,
healthcare providers, and healthcare clearinghouses. Health plans include
health insurance companies, health maintenance organizations, government
programs that pay for healthcare (Medicare for example), and military and
veterans' health programs, who electronically transmit any health information
in connection with transactions for which HHS has adopted standards.

BUSINESS ASSOCIATES: A “business associate” is a person or entity that
performs certain functions or activities that involve the use or disclosure of
protected health information on behalf of, or provides services to, a covered
entity. A member of the covered entity's workforce is not a business associate.

PHI: PHI stands for Protected Health Information. The HIPAA Privacy Rule
provides federal protections for personal health information held by covered
entities and gives patients an array of rights with respect to that information.

EMR: An EHR or electronic health record is a digital record of health
information.

TAT: Turn Around Time.