Medical transcriptionists are responsible for documenting the procedures performed by doctors and other medical personnel.
They take dictation using either shorthand or a stenotype machine, or headsets and transcribing machines, for a variety of medical reports such as patient histories and care, physical examinations, emergency room visits, operations, chart reviews, consultation, correspondence, research, administrative material and discharge summaries.
The next step it to convert the dictated information or rough notes into written form. They need to review and edit the transcribed reports or dictated material for spelling, grammar, clarity, consistency and correct medical terminology, and translate medical jargon and abbreviations into their expanded forms to ensure the accuracy of patient and health care facility records. They then return the dictated reports in printed or electronic form for review by the physicians concerned, for their signature, and any corrections, and for inclusion in patients’ medical records.
They also need to set up and maintain the medical files and databases, including records such as x-ray, laboratory and procedure reports, medical histories, diagnostic work-ups, admission and discharge summaries and clinical resumes.
The finished notes and reports are considered official medical documents and are referred to if patients require future treatments, and used for legal testimonials and insurance processing.
Schooling & School Subjects
It would be an advantage to be fluent in speaking and writing more than one of the more widely used official languages. Experience and knowledge are gained through in-service training, or by taking an appropriate degree or diploma course at a university of technology.
Training can be done on-line at the address Transcribe SA, below. Medical Secretary courses are also offered at the Academy of Learning and Intec.
Tel.: 082 45 88867 Fax.: 086 6484853
South African Secretaries and PA’s Association
P O Box 2517
Tel: (011) 454-5505 Fax: (011) 454-5501