Medical Transcriptionist

What is a medical transcriptionist?

A medical transcriptionist is a healthcare professional who converts voice recordings into written reports. Primary care physicians and other healthcare providers create voice recordings to quickly save appointment notes. Instead of listening to these recordings, you’ll see reports in your electronic medical records or health portal. Medical transcriptionists likely play a role in creating these records so you and your provider can access them later.

You see your healthcare providers in person and have conversations with them. But you’ll probably never meet your medical transcriptionists. They’re like the stage crew behind the curtains that makes sure the show goes on smoothly and safely.

Transcriptionists must know medical concepts and terms to ensure your medical notes are accurate and clear. It’s a high-stakes job. Mistakes in medical reports that seem small could have a serious impact on your health. This sense of responsibility, as well as the fast-paced nature of the job, may cause stress for medical transcriptionists.

Advances in technology are changing the field. For example, transcription software can convert voice recordings to written transcripts with increasing accuracy. As a result, employers (like hospitals) may not need to hire as many new transcriptionists. But it’s still an important role that’s worth knowing about, whether you receive care in a medical setting or are interested in working in the field. Medical transcriptionists are part of the larger team that supports your health and helps you get the care you need.

Another name for a medical transcriptionist is a healthcare documentation specialist.

Where do medical transcriptionists work?

Medical transcriptionists work in many different settings, including:

• Administrative offices (for companies that offer transcription services).
• Healthcare providers’ offices.
• Hospitals.
• Medical and diagnostic labs.

Some medical transcriptionists work from home. Most jobs are full-time.

What does a medical transcriptionist do?

Medical transcriptionists use technologies to convert healthcare providers’ audio recordings into written reports. For example, they might use speech recognition software to convert a recording into a written report draft. But using technology is just one part of their job. They must also draw upon their knowledge and critical thinking skills to:

• Listen carefully to each recording and compare it against the report draft, making sure the report is accurate.
• Correct errors in reports.
• Find inconsistent or missing information that could put your health at risk.
• Change jargon and abbreviations that providers might use into full words or phrases.
• Submit reports to providers for approval.
• Put reports into your electronic health records.
• Follow legal guidelines to keep your information safe and private. Medical transcriptionists treat the information they transcribe as confidential.

What is the difference between a medical transcriptionist and a medical scribe?

Medical transcriptionists work behind the scenes. They’re not with you during your appointment. Instead, they document information after your appointment from another location.

Medical scribes, or documentation assistants, work alongside healthcare providers in real time. They’re present during your appointments and document details as they happen. Scribes help your provider save time and focus on you during your appointment. College students often work as scribes to gain experience before applying to medical school.

What knowledge and skills does a medical transcriptionist need?

Medical transcriptionists should have:

• Familiarity with anatomy, physiology and medical language.
• Critical thinking skills to find and fix mistakes in completed reports.
• Writing skills and knowledge of grammar to review reports for accuracy and clarity.
• Listening skills to pick up the words and intended meanings of healthcare providers’ recordings.
• Computer skills to use electronic health records (EHR) systems and software for creating reports.
• Time management skills to create reports quickly and by deadlines.

How do I become a medical transcriptionist?

You can become a medical transcriptionist by:

• Earning a high school diploma or GED.
• Taking classes to earn a medical transcriptionist certificate.
• Taking an exam to earn a medical transcriptionist certification (an optional credential).

Medical transcriptionist training usually involves taking classes online or in person. You can complete many programs in under a year to earn a certificate. Your program may take longer if it involves earning an associate’s degree. Your training will give you knowledge in:

• Anatomy and physiology.
• Medical language.
• Legal issues and how to protect patients’ privacy.
• Grammar and punctuation.

The Association for Healthcare Documentation Integrity (the professional society for medical transcriptionists) offers a list of approved programs on its website. They also offer other resources to help you choose a program and develop your career.

Medical transcriptionist certification

You don’t necessarily need a medical transcriptionist certification to work in the field. However, many employers prefer to hire people with certification because it shows you have the skills and training to do your job well.

The Association for Healthcare Documentation Integrity provides several certification options. You need to pass an exam to earn each credential. Your certification will last for a certain number of years. Keep in mind that you’ll need to earn continuing education credits to stay certified.

The types of credentials you can earn include:

• Registered Healthcare Documentation Specialist (RHDS): This credential is appropriate if you’ve recently graduated from a medical transcription program or have fewer than two years of experience in acute care. It’s also suitable for transcriptionists with experience in one type of specialty (like private practice or a lab).
• Certified Healthcare Documentation Specialist (CHDS): This is a next step if you already have the RHDS credential. You should have at least two years of experience transcribing in an acute care setting (hospital, emergency department or urgent/express care) or in multiple specialties.
• Certified Healthcare Documentation Professional (CHDP): This credential is for anyone who plays a role in healthcare documentation, including allied health professionals and scribes.

Job outlook

The U.S. Bureau of Labor Statistics predicts that employment for medical transcriptionists will decline by 7% from 2021 to 2031. Advances in technology are a main reason. Some new technologies either replace the need for transcriptionists or make their work more efficient (meaning fewer people can do the same amount of work).

But there’s still good news. Experts predict an average of 9,300 medical transcriptionist job openings each year in the U.S. from 2021 to 2031. That’s because some people switch jobs or retire, and employers need others to fill their roles. So, if you’re interested in this career, there’s room for you to explore and find a job where you can make a difference in others’ lives.

A note from Cleveland Clinic

Think about an important phone call you’ve had recently. Right after you ended the call, the details were probably sharp in your mind. But a few days later, they might start to fade. Recalling them a few months later would be hard, if not impossible. It’s similar in healthcare. Conversations happen every day. Providers give you information and advice, and you hear it in the moment. But those words may start to fade for both you and your provider without a written record.

Medical transcriptionists help make sense of all those words and compile them in a clear, organized format. These reports make their way into your electronic medical records. And these records allow you and your healthcare provider to recall important details long after your appointments. This information helps you receive the best possible care tailored to your changing needs. If you have questions about your medical records or how to access them, don’t hesitate to ask your provider.