| The Medical Transcriptionist is a Vital Link in the | | | | Physician's evaluation - Treatment - Conclusions |
| Delivery of Patient Healthcare The hospital | | | | The Medical Transcriptionist may need to |
| admission sheet or patient demographic face | | | | transcribe a dictated note with a comprehensive |
| sheet contains: - Patient's address - Next of kin - | | | | visit that might include: - Diagnostic test results - |
| Birthplace - Social security number - Occupation - | | | | Consents - Instructions Physician's office |
| Sex - Marital status - Ethnic origin - Religious | | | | healthcare records are maintained in the |
| preference - Admitting diagnosis - Financial entries | | | | physician's office and may include: - Many, but not |
| that include patient's employer, job title, address | | | | all, of the same records and forms contained in |
| of company, insurance company, person | | | | the hospital healthcare record - Initial history and |
| responsible for emergency notification and | | | | physical exam - Office visit notes - Progress |
| payments, type of coverage, insurance | | | | notes - Diagnostic test results - Copies of acute |
| identification number, type of payment plan The | | | | hospitalization reports - Letters to insurance |
| hospital is required by federal law to collect this | | | | companies - Consultation letters The Medical |
| minimum amount of information, which is | | | | Transcriptionists plays a vital role in the delivery of |
| recorded on the admission face sheet and | | | | healthcare while accurately transcribing timely data |
| available in some format to the Medical | | | | entries that communicate illness and wellness |
| Transcriptionist to assist in patient identification. | | | | information throughout the healthcare system. |
| The Medical Transcriptionist's role here is to | | | | Medical transcription requires physical skills of |
| transcribe this information with complete accuracy | | | | coordination of your eyes, ears, fingers, and foot |
| in a timely manner. The admissions department is | | | | (if you use a foot pedal). You should be an |
| also responsible for obtaining a consent form | | | | accomplished typist having a copy typing speed |
| which includes: - Patient's consent for treatment - | | | | of at least 45 words per minute before |
| Outline of patient's responsibilities including billing - | | | | attempting to transcribe. You should also expect |
| The assurance that confidentiality will be | | | | your transcription to be slow and halting in the |
| protected Other informed consents for surgery, | | | | beginning as medical transcription does require |
| procedures, invasive diagnostic tests, transfer, | | | | somewhat different than copy typing. This article |
| etc. will be obtained as appropriate. Medical entries | | | | is FREE to publish with the resource box. © |
| of the patient's healthcare record include: - | | | | 2007 Connie Limon All Rights Reserved |
| Physician orders - Diagnostic tests - Nursing | | | | Connie Limon, Medical Transcriptionist. Visit us at |
| entries - Physician entries - Therapists' entries - | | | | for more information about the unique and |
| Ancillary personnel entries Emergency record: | | | | rewarding career choice of Medical Transcription. |
| Patients evaluated and treated in the Emergency | | | | Visit Camelot Articles for a variety of FREE |
| Department receive a condensed version of the | | | | reprint articles for your newsletter, web sites or |
| inpatient healthcare record that includes: - | | | | blogs. |
| Demographic information - Nursing assessment - | | | | |