How to Transcribe a Pathology Report

Medical transcription requires a basic knowledge of many medical terms and phrases. Knowing these words will help you identify and type them in an efficient and effective manner. Pathology reports contain a diagnosis as determined by visual, physical and microscopic examination of cells, tissues and the body.

Things You'll Need

• Computer
• Headset
• Foot pedal
• Word processing software
• Audio playback software

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Instructions

• 1

  Install your word processing program. Any of the programs used to format documents work to provide proper transcription formatting.

• 2

  Download the audio playback software. Scribe is the most commonly used system and is designed to work with a foot pedal.

• 3

  Upload or download the audio for the pathology report. Different labs and hospitals will provide the audio in varying ways. Some places upload to a collective site where you download the files with your unique log-in and password. Other locations will mail the information via a thumb drive.

• 4

  Connect your foot pedal and headset to the computer. Depending on your outlets, the pedal will connect via USB port or firewire. The headset works directly through the normal audio output connector.

• 5

  Open both a blank word processing document and the pathology audio file.

• 6

  Listen to the audio as you type. Stop the progress of the audio by using the foot pedal. This allows you to catch up while you are typing. In general pathology reports should start with the patient name, hospital number, pathology report number, admitting physician, preoperative diagnosis, postoperative diagnosis, type of specimen submitted, date received and date reported.

• 7

  Finish the entire report, which will detail both the macroscopic exam and the microscopic exam. The pathologic diagnosis will be listed, and you will finalize the transcription with the dictation date and the transcription date.

• 8

  Format and proofread the entire document. Change anything that is not correct, and complete any specific formatting requests by the company for which you work.

• 9

  Turn in the pathology report through the appropriate method, such as uploading to an encrypted website or sending via email.