For nearly two years, I have been taking an online course in medical transcription through CareerStep. The first four months were pure knowledge building of the medical field, learning all about the body, diseases, medications, injuries, laboratory data, x-rays, and surgeries. Actually, it was thrilling and I loved it! My brain became young again and absorbed the words, phrases, and facts with great fervor. I bought a bunch of medical books and found many medical websites to aid in correctly transcribing medical reports. (www.accessdata.fda.gov/, www.medilexicon.com/, www.drugs.com/)
Since then, I have been learning to transcribe all sorts of reports from various medical areas – clinical, radiology, hospitalization, surgery, death – in all the different fields and specialities. CareerStep has been very thorough in its offerings of dictated reports(850): cardiology, orthopedics, ophthalmology, pediatrics, pulmonary, gastroenterology, genitourinary, obstetrics and gynecology, neurology, endocrinology, psychiatry, otorhinolaryngology, geriatrics, pathology, oncology, dental, and infectious diseases. The treatment of injuries/trauma, chronic diseases/conditions, infections, diabetes, psychosis, inflammation, paralysis, birth defects, cancer, hereditary diseases/conditions, and more has been well covered. Right now I feel almost like a physician’s assistant…Well, at least like a nurse. There is so much one has to know and understand in order to become a top medical transcriptionist.
However, no amount of knowledge or intelligence will be of much help without the ability to discern what the doctor is dictating. Throughout the plethora of reports I have transcribed, there have been quite a few atrocious dictators. Men and women, English-speaking and not, who enunciate with excruciating disregard for the listener.
Dictated reports became a required necessity, decades ago, after too many patients died and the reasons could not be determined by their charts or because surgeons closed incisions with gauze pads and instruments still inside the body. Without the correct information in a person’s chart havoc, injury, or even death could result. That doctors dictate in a clear and concise manner would seem to be simply common sense. But nooooo, too many doctors do not dictate any better than they write. They rely on transcribers to clean up their garble and return a viable report. The reports that become a part of any patient’s record must be accurate to the nth degree to ensure that the he/she is not put in harm’s way, i.e. being given the wrong drug or having an incision made in the wrong area. Knowing that inaccurate data could be hazardous to a patient’s medical treatment, or even life, should be foremost in a doctor’s mind and, therefore, dictation should be easily discernible. However, doctors are very busy people and, being human, certainly not without flaws. After hundreds and thousands of patient reports, they cannot help becoming heedless of the threat posed by their poor speaking skills. Having to dictate a report becomes a repetitive and bothersome chore for many physicians/surgeons, made necessary due to incompetent physicians of the past.
When a medical transcriptionist is unsure of a term/phrase/medication, a “blank” is inserted into the report, flagged, and returned for clarification or verification. This blank is supposed to be reviewed by the doctor or medical facility and corrected; however, that is not always the case. Too often, believe it or not, a doctor will blindly sign-off on an incomplete report, which then becomes a part of a patient record. Imagine the possible harmful outcome that could occur from this irresponsible conduct! Why are doctors allowed to get away with this?
The answer is obvious, of course: Time, numbers, and space. 1)There isn’t enough time in the day for the busy doctors to read extraneous material, let alone take the time to correct it. 2)They have too many patients to attend to. Hundreds of thousands of people a day are seen by too few doctors, overstressed and exhausted doctors. Every day these doctors cannot leave a hospital or clinic until they have dictated a report on each man/woman/child they have seen or operated on. 3)If they choose to dictate a report after seeing each patient or every few patients, they usually have to do so at a noisy, non-private station. Most medical facilities do not have a private office for each doctor. Thus, the circumstances under which physicians/surgeons/radiologists dictate correlate directly to the resultant speed, concentration, and enunciation of their dictation. However, regardless of these factors, a medical professional’s most important responsibility is to patient health.
The main purpose of this post is to reach out to medical dictators and facility administrators, who rely on medical transcriptionists, and remind them that poor dictation could lead to dire consequences for patients and to malpractice suits for healthcare providers. What good does it do to mandate that reports of every visit, treatment, and procedure be included in patient records, if the dictation is so poor that the reports are rendered inaccurate, maybe dangerous, by their incompleteness? Doctors and radiologists need to slow down and perfect their enunciation skills, as well as take the time to fill-in any blank in their reports. (Clear dictation = no blanks.) Facilities, for their part, should provide quiet areas for dictation; plus, hire a few more physician assistants to relieve the overflow of patients.
As a patient, caregiver, and transcriptionist, a most heartfelt thank you to all responsible contributors of accurate medical reports.