All Things Transcription

Abbreviations can be frustrating things, especially for medical transcription students. I have heard of many variations regarding this subject being taught by different training programs. Before we go any further, let me state that you should always remember to follow your account specifications first and to follow BOS (Book of Style) guidelines second regarding abbreviation rules if rules are not clearly spelled out in your account specifications. Once you begin working, you will find this is an often debated subject with many exceptions. You may find that your account specifications require making exceptions regarding abbreviations that are uncomfortable to you due to your recent training.

I will state that I will not under any circumstances transcribe an abbreviation that is on the JC’s (Joint Commission, formerly JCAHO) list of dangerous abbreviations. I feel that it creates too great a personal liability for me to do this. This is the official “Do Not Use” list. Having said this, I will tell you that I have had 2 situations come up where accounts wanted to use one of the abbreviations on this list. Hard to believe, I know. In the end, JC standards won out, but I still would have refused to transcribe these. As a new medical transcriptionist, you will have to make your own decision about this if you find yourself in this situation.

First and foremost, if you are currently enrolled in a medical transcription training program, I would suggest that you obtain a copy of the BOS and begin to familiarize yourself with the contents. Rules regarding abbreviations are complicated, so get a head start. While you are doing this, realize that you will come across many situations that will require you to ignore what you learn according to the desires of facilities and doctors that you work for.

Generally, you will find that some types of abbreviations are always acceptable: Metric measurements in any context, most laboratory studies (TSH, CBC, BUN, etc.) and some surgical aids (PDS sutures, GIA staplers). Again, there are always exceptions to this, refer to your account specifications.

You may also want to be aware that some children’s hospitals require expansion of abbreviations throughout the entire document so that parents can more easily read and understand the reports pertaining to their child’s medical treatments.

Another important thing to remember about abbreviations is that many of them may refer to more than one condition. Most of the time, the medical transcriptionist will be able to choose the correct expansion based on information in other parts of the report. Some dictators will automatically expand the abbreviation in the diagnosis/diagnoses portion of the examination, or if you have access to other records regarding a particular patient you can sometimes find the information there. If you are unsure of an abbreviation DO NOT expand it. You must either leave the abbreviation as is or flag the report. As in all other aspects of this profession, you MUST NOT guess! I repeat, DO NOT GUESS!

It would be great if there were better consistency regarding the dictation of abbreviations and the rules pertaining to expansion. Even when account specifications are clear, there can still be confusion. For example, your specifications state that you should always expand in the diagnosis/diagnoses section of the report. This sounds simple until you realize that some dictators will dictate this section with another heading name such as “problem list.” The doctor may clearly consider this to be the diagnosis/diagnoses section and he/she wants abbreviations expanded as he/she dictates them in expanded form. Obviously, you would go ahead and transcribe those verbatim. However, if the dictator expands all of these terms except one in that section and the account specifications state that you only expand under “diagnosis/diagnoses, do you go ahead and expand the one term that the dictator did not expand? See what I mean? You may find yourself constantly bugging QA about issues such as these until all of the exceptions are ironed out that pertain to this issue within the account specifications.

This is an almost constant debate and, until there is some consistency established in dictation methods, the debate will continue. The saving grace is that many doctors dictate consistently no matter what their chosen format is. Some of them can be very particular and will specify that they want their reports transcribed in their chosen fashion at all times with no exceptions. In a perfect world, all dictators would know what they want and be able to state it in clear and concise terms.

What it boils down to is that the subject of abbreviations will constantly come up in your career as a medical transcriptionist. It is one of those things that mean you will never be bored in this profession and you will constantly be required to learn new things. Just remember that this is what makes it fun!

In many cases, to obtain a job in medical transcription you must pass a pre-employment test. These tests usually consist of an objective portion and a transcription portion. The objective portion of the test may include questions regarding medical terminology, spelling and grammar and fill in the blank. Occasionally, the objective portion is timed. Usually the objective portion of the test is completed and the invitation to proceed with the transcription portion of the test hinges on your score on the objective portion.

There are some general hints regarding test taking that apply to medical transcription pre-employment tests that may help the recent graduate with passing these tests. Most importantly, try to relax. Yes, I know, the entire process is nerve racking. However, if you are exceedingly nervous, you may misread the instructions for the test right off the bat. This is an immediate recipe for disaster. Perhaps you placed a punctuation mark within a fill in the blank answer out of habit but the instructions cautioned you not to do this. You did not see the instructions in the grammar portion stating to type “correct as is” if the sentence is punctuated correctly and just left it blank. Even though you know the material, because you did not read the instructions carefully, the answer is incorrect because you did not follow the test format.

If the test gives you the opportunity to save the answers in each section, do so. Computers are contrary things and, if you use this feature, it can save you a lot of trouble if your computer crashes or the test site experiences problems. The answers you have completed will still be there when you log back into the test site. If the test is timed, this can be crucial since it allows you to pick up where you left off instead of wasting valuable time reworking sections you have already completed.

Always make sure that you clicked the correct answers before you save the section. Even if the test is timed, you must take the time to glance back over each question to ensure that you haven't mistakenly clicked the wrong answer. How disappointing to receive a poor test score and then find out that you would have gotten one or two more correct answers if only you had taken this step.

Most medical transcription pre-employment tests allow you to use any research materials that you choose. Make use of these! Research is something you do every day on the job, so why take a chance. Even if you are 100% sure about an answer, check it anyway. That may be the one that you clicked the wrong one on. I would also suggest that if you get stuck on something, move on and come back to it. Just do not forget to come back to it. This is standard test taking advice and it is good advice. If the test is timed, why take the chance of not having the time to answer the ones you do know because you spent too long on one question. At least it gives you the opportunity to only miss that one question you left blank.

Have your chosen references close at hand and ready to go. If you use specific websites, make use of the tab feature and bring up the ones you feel you will use beforehand to avoid wasting time during the test. You don't want to find out the site you usually use for abbreviations is down and have to spend time looking for another one. Never forget, Google is your friend! However, make sure you choose a reputable site. Do not just glance at the page of results and accept what you see in the site synopses at face value.

You may find in the spelling and grammar sections that you will be looking for grammatical, punctuation and spelling errors in the same sentence or paragraph. This will be followed by multiple choice answers or boxes to fill in the misspelled words or both. Be very careful with this format. Make sure that you have clicked the correct answer buttons and make sure not to use punctuation in the boxes unless instructed to do so.

If you are invited to continue the test with the transcription portion, again, do not panic. Take a deep breath. Relax. Make sure you have enough time to complete the test in the time you are given to complete it. If references are allowed, follow the advice above. For the record, I have yet to hear of any pre-employment test that does not allow references.

Regarding blanks or flags on transcription tests, NEVER GUESS! I see many people getting their panties in a wad about this subject. How many blanks are good/bad? What should I use for blanks? Should I use parentheses? Underscores? Should I include (s/l)s? I use 5 underscores for blanks at work. I would do the same for a test. This is just my preference. Just make sure that the format you use is clearly a blank. The most important thing here, again, is that you just DO NOT GUESS. You will not do this in a work situation, you do not want to do this on a test. Guaranteed fail. Epic fail. You just will not get a job this way. You cannot fake it if you do not know it.

That being said, we have all either heard horror stories about or have been on the receiving in of some of the worst dictations known to medical transcriptionists. Chewing, sneezing, ringing phones, mumblers, auctioneers, page shufflers, film rattlers and, of course, "Is that doctor really speaking English?" You may find one of these on your test. Again, do not panic! Most companies want to see what you will do with these. "But I can't turn it in with 15 blanks," you say? Yes, you can and that is probably what they are expecting to see from a new medical transcriptionist. Better 15 blanks then guessing. Have I mentioned NOT TO GUESS?

Listen to the dictation, transcribe it, do a second pass, a third pass, read it backwards, read it out loud, print it out and use a red pen. It does not matter what you do to make sure you have done your very best on the transcription portion of your pre-employment test, as long as you do your best every time you take one. Indeed, you may expect to fail a few. Keep taking them. It is excellent practice.

It is also worth mentioning here that you do not want to use any forum to ask questions while you are testing. Not your school forum and not industry forums. Do not even consider it. No matter how desperate you are. It is better to fail the test than to participate in this kind of cheating. You may think that no one will find you out, but they will. You may be banned from the forum. Worst case scenario is that someone notifies the company that you are testing for of this transgression. You may find yourself unable to obtain any type of employment if word of this gets around. It is, after all, a small community.

If you have graduated from a reputable training program, you will be able to find gainful employment as a medical transcriptionist. Be confident that even if you fail a few tests, you will pass some too. Then all you have to worry about is what job offer to take! Good luck and happy testing!

A couple of years ago, I saw the handwriting on the wall and decided to train for a new career. I spent many long years working in retail clothing and, after a couple of years working in a hospital setting, I went back to this career. Bad mistake. The company I returned to work for began to show signs of failing. Once I read the writing on the wall, I started to consider a career change.

In the midst of my retail career, I worked in a local hospital Emergency Room. I enjoyed the job very much, but decided to once again to return to retail due to lack of benefits in the position I held in the Emergency Room. When it came to deciding on what kind of retraining to embark on, I started looking around in the healthcare field. One of the main problems with the ER job was the fact that it took so much time away from my family. I began to consider medical transcription. I could work from home and I would still be involved with continuity of care for patients.

I began training before the clothing company I worked for began admitting that the problems they were having were serious. (That writing on the wall thing I mentioned above.) I took my final examination just about 3 weeks before the company closed for good and began the job search. I had some fill in work locally. I accepted a job for a small MTSO, but that’s a subject for another post. Then I began working for the company I currently work for. It’s great! I love it! There just couldn’t be anything better for me. For the first time in a very long time, I love my job! I love medical transcription!

I work from home. I do not have to leave the house if I do not want to. This saves gobs of money due to the fact that my car stays parked most of the time, saving on wear and tear and gas. I only have to fill up about once every 6-8 weeks. I no longer have to buy business clothes. The official uniform of the medical transcriptionist is pajamas! I am no longer tempted to buy vending machine snacks and sodas; hence I have been able to control my soda addiction. I cook the majority of our meals here and, since I love to cook, this is also a tremendous bonus in terms of money saved and job satisfaction.

I love medical transcription because it is never boring. I learn something new everyday and I feel that I am an important part of patient care. I never dread “going to work” because I only have to sit down at my desk in my own home. I work in acute care which accelerates the learning process as a medical transcriptionist. At least once a week, if not more often, I get a type of procedure or condition that is new to me so I always feel that I am advancing my knowledge.

For me, the level of job satisfaction I have has increased exponentially as a medical transcriptionist compared to my former career in retail clothing. Knowing that the report you are transcribing is contributing directly to patient care puts helping someone find a sweater in the shade when it comes to being satisfied with your career choice. Medical transcriptionist is an important part of healthcare. Knowing that the Preop History and Physical I am transcribing must be accurate to ensure the operating room staff is fully prepared for the patient's surgery or the Discharge Summary I am working on will help a patient go home with the information they need to ensure continued recovery is very satisfying.

Medical transcription can also be incredibly frustrating. Bad dictators, poor audio and the other problems that accompany the aforementioned can be enough to make a transcriptionist want to pull their hair out. Sometimes the day can be pretty bad and it can be pretty hard to be positive. However, I have yet to regret making the decision to change my career and become a medical transcriptionist. Life is good!

As medical transcriptionists, we must always be aware of the quality of our work. That is, or at least should be, the number one priority at all times. However, we also all want to make as much money as we can in order to meet our obligations. How do we do this efficiently?

We all know about text expanders and they are a useful tool. They increase production exponentially as we add to them. There is another tool, however, that you may not have thought of, the simple Excel spreadsheet. For the last several months, I have been utilizing a spreadsheet to keep up with my production. By doing this, I have been pleasantly surprised by how much my production has increased.

I believe this increase is mostly due to the natural progression of things in the medical transcription profession. There are plateaus that make our production rates stagnant. As we add to our store of terminology, become familiar with our speakers and utilize text expanders more efficiently, we increase in the speed at which we can produce quality reports.

However, an Excel spreadsheet can give us a psychological boost that shows up in the numbers by, well, showing us the numbers.

I have included the following information on the spreadsheet:

1. Edited lines.
2. Edited lines x cpl.
3. Standard lines.
4. Standard lines x cpl.
5. Total lines.
6. Total earned.
7. Hours worked.
8. Lines per hour.
9. Number of reports typed.
10. Ratio of VR to ST produced.
11. Dollar per hour.

Hours worked is the actual time spent working per the platform, not the total time including research. This gives a somewhat inaccurate figure. However, it is easier on the psyche to keep up with this figure at first since we are not usually paid for time spent researching, etc.

Lines per hour is again a somewhat inaccurate figure since it combines both VR (Voice Recognition) and ST (Straight) transcription. The platform keeps up with them individually so I would rather have a combined representation here.

Number of reports really has no bearing on the final figures since the reports are not the same length. However, it is fun to look at and offers a reality check. There are days that I can put out a large number of reports and barely make my personal goal for the day and days that I can type relatively few reports and make those goals in fairly short order. The question "How many reports do you do in day" is a common one asked by new medical transcriptionists. This answers that question with "it depends."

Ratio of VR to ST produced showed me very quickly that I can actually make more money with VR even though the pay rate is half of ST. Voice recognition is also something that proves the medical transcription field will not go away with this technology. It will only change how we work.

The dollar per hour figure can be disheartening. Especially when you end up with a horrible speaker or an unfamiliar speciality that eats up lots of listening or researching time.

This information is tied into the chart function in Excel and I can see a graphical representation of my progress. I believe that this feature is what has helped more than anything else. I get all excited when the graph is trending up! That motivates me to keep it moving in that direction. This is the psychological part that I mentioned. Even over a very short period of time there is a motivational factor present. If the money dipped down the day before because of one of the aforementioned reasons, it motivates me to get that one more report done before it is time to start dinner so I can improve just a little jot over yesterday.

It has also helped me in making a schedule that is both suitable for me and my family and is also the most helpful for my employer. Since using the spreadsheet as a scheduling tool, I find that I am usually working when I am most needed and always have a steady flow of work available. Of course, I am very lucky in that my account has lots of steady work. However, there are still slow times and it behooves me to avoid those so that I can be available when the reports are flowing in at an alarming rate. This means I work most weekends and holidays, but I expected that going in. Hospitals do not close, now do they? The new medical transcriptionist must realize that and, if they are independent contractors, tailor their schedules accordingly.

At any rate, the spreadsheet is a great tool that will help you keep motivated and boost your production rate. Excel is pretty easy to learn. If I can do it most anyone can, believe me. You can click here for Microsoft’s online tutorials. You can also use Google to search for specific instructions on productivity sheets and also really easy beginner tutorials if you have never attempted this before. The ability to make a spreadsheet is a great skill to have. They have many uses: Scheduling, bill paying, budgeting, etc.

Give it a try for a couple of months and you may be pleasantly surprised. It helps prevent panicking about never being able to make any money in the field of medical transcription. After all, we could all use a little less stress, can’t we?

I thought I would say a few words about the current state of medical transcription salaries. The field has long been popular as a legitimate way to work from home. It sounds like a dream come true for parents with small children who want to be able to spend more time with their family. Training opportunities are now freely available online, easing the way for people who cannot find the time to attend a traditional school or have no local program nearby. However, it is difficult to find accurate information regarding salaries.

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