How to Transcribe Medical Records

Many people looking for additional income take on the task of medical transcription. Medical transcription is the practice of taking a doctor or surgeon's dictated notes and typing them out for inclusion in a patient's chart. Some items that may need to be transcribed include letters and lab reports, operating room notes, history and physical information and patient consultations. Typically, this is done by someone using either a transcription machine or a digital system. It's good work if you can find it, but it does require a certain degree of skill and effort.

Things You'll Need

• Transcription machine with headphones
• Computer with word processing software

Show More

Instructions

• 1

  Take a course in medical transcription. Do this before you do anything else. It's one of the best ways to get a feel for how medical transcription works, and it will allow you to brush up on your medical terminology. There are some medical transcription courses available online, and you may wish to look into these as well. Once you've mastered the basic skills of medical transcription, you can move on to the next step.

• 2

  Listen to a physician's recorded notes. This can be done by way of a digital system that is fed into an MP3 file on your computer. It can also be done when the physician speaks into a voice recorder. A tape is then provided to the transcriptionist. As you listen to the tape, adjust the speed of the playback as needed. Use the transcription machine's foot pedal to pause and rewind the playback.

• 3

  Type the physician's notes into your word processing program. Most doctors have a specific format they prefer to use in their dictation, and if you transcribe for more than one doctor, it is a good idea to set up templates for each of them, depending on how they typically dictate their medical records. Use your word processor's macro tools to set up a template.

• 4

  Go back and check spelling and grammar. Do this after you've finished the letter or office report. Be sure to have a good medical dictionary handy to check unfamiliar terms. If there's anything you're unsure of, you may want to call the physician's office to check. Accuracy is important when it comes to healthcare records.

• 5

  Print out the medical records report. Once you've done this, return it to the surgeon. Be sure that you have determined in advance how corrections are to be made. If the surgeon plans to review your transcribed report and make corrections on it, you'll need to make the necessary changes and print it out again for the doctor's signature.