The Medical Transcriptionist’s Role in Editing Physician Dictation

Medical writing differs in technique from writing essay and manuscripts for publication. The writing of an essay or manuscript requires adherence to prescribed forms, style, and syntax. The writer often generates several draft copies before finishing a polished document for publication.

Medical writing by contrast contains many abbreviations, brief forms, shortcuts, and word coinages that are an integral part of the language of medicine. It is not feasible or expected for a Medical Transcriptionist working in a fast-paced environment to convert the medical document into a piece of formal writing or a polished essay piece of writing.

Medical Transcriptionists are expected to produce clean, neat and accurate medical documents for every medical report dictated and to follow suggested or prescribed stylistic guidelines common to the Medical Transcription field or according to the agency he or she works for.

A lot of the stylistic rules of Medical Transcription relate to proper editing, punctuation, and grammar. You will find that even the most respected reference materials vary and contradict one another and themselves. The employer of a Medical Transcriptionist may mandate specific rules of grammar, style and format to be followed. In this case, the Medical Transcriptionist is required to follow the styles and formats mandated by his or her employer. In the absence of these, he or she can follow the common rules set forth by instructors of Medical Transcription and other experienced Medical Transcriptionists.

Editing

You will never find a perfect dictator! Every dictator has at one time or another misspoke and said something like, “The patient smokes two beers a day and drinks two packs,” or refers to surgery on the left arm in one paragraph and surgery on the right arm in the next paragraph. Busy dictating physicians count on the Medical Transcriptionist to be alert. When necessary, he or she must correct the mistakes of the dictating physician. Most of the time you won’t be required to put coffee on and have a cup of coffee waiting for the dictating physician, unless of course, you do this just out of courtesy, which can be nice, warm and friendly, when working in small environments or medical clinics. However, you will be required to correct his or her dictating mistakes.

Editing physician dictation is easier if you work with the same physician each day. You become accustom to their unique style of dictating. However, for those who work with 100’s of different dictators, it is experience and a firm grasp of medical language and terminology that becomes your number one tool for editing.

When necessary, the transcriptionist may add conjunctions, prepositions, articles, pronouns, nouns, and verbs to complete a sentence and help make sense of sentences.

Examples:

Physician dictates: No tenderness present over chest
Transcribed: No tenderness is present over the chest.

Physician dictates: Came in with chest pai

Transcribed: The patient came in with chest pain.

It is also acceptable to type all of the above as dictated. This preserves the style of the dictator.

In my first job as a Medical Transcriptionist in a small state run Crippled Children’s Clinic, I was instructed to type exactly what the physician dictated. I only changed or edited sentences such as when doctor dictates throughout the report he or she performed surgery on the left leg, and then suddenly changed it over to the right leg before the report was finished. And when I made such a change, I carefully read previous dictations and diagnosis of patient to be certain which leg the doctor actually performed surgery upon!

The Medical Transcriptionist should never edit physician dictation aggressively. It has to be done subtly, delicately and carefully. You want to always strive for a favorable response from the dictator. You need to be involved and alert while transcribing medical dictation so that when something is dictated that just does not make sense, which does not flow, or does not add up, you will immediately detect it. Listen with an intelligent ear to produce accurate, intelligent, clear medical documents. Keep in mind the fine line between “editing” and tampering.

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