Transcription tales

Being a corporate trainer in a medical transcription company can have its mix of heady days when there is an overload of medical reports coming in from hospitals across America, which are sheer pleasure due to the humour involved in the training experience. Needless to say, the mirth generated by the trainees transcribing dictated reports, with words very different from what has been dictated, results in laughter being the best medicine and serves as a potent stress buster indeed.

Many a time when one is flipping through the ‘Jaamt’ (‘Journal for American Association of Medical Transcription’), one comes across a range of topics which are important as they throw up several medico-legal issues. As a trainer, I always tell my trainees about the importance of referencing and documenting all medical terms and medications in order to produce error-free reports. Reports should be transcribed with application of one’s greycells and inadvertence is apt to be considered with not much amusement by those offering dictation.

Whether the report is paediatric, gynaecological or orthopedic, one must see that the words make absolute sense. Thus, I almost did my nut when one trainee transcribed “Normocephalic and atraumatic”, as “Normocephalic and automatic”!
Trainees have repeatedly been told to use their common sense while transcribing. As a trainer, however, I would say that using ‘common sense’, an uncanny intuitive ability, is not always common. The trainees are of two types, either they are perfectionists who go the extra mile to refer to reference books and periodicals, or the other category being those who are just plain lethargic. The latter would want to take short cuts to get words instead of exercising their brains and doing hard work. One of those bloomers, a trainee committed was to transcribe “The patient is a 73-year-old female”, as “The patient is a 73-year-old e-mail!”

Another instance of lack of common sense I have come across relates to the use of capital letters, Roman or Arabic numbering, and in short, the style of medical transcription, as such. One of the trainees transcribed, “The patient has Pneumonia,” with a capital P. Asked why he had done so, pat came the reply, “Ma’am, because it is the name of a disease!” I guess on some days you just don’t win.

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