The Medical Transcriptionist's Role in Editing Physician Dictation

Medical writing differs in technique from writingsmall environments or medical clinics. However,
essay and manuscripts for publication. The writingyou will be required to correct his or her dictating
of an essay or manuscript requires adherence tomistakes.
prescribed forms, style, and syntax. The writerEditing physician dictation is easier if you work
often generates several draft copies beforewith the same physician each day. You become
finishing a polished document for publication.accustom to their unique style of dictating.
Medical writing by contrast contains manyHowever, for those who work with 100's of
abbreviations, brief forms, shortcuts, and worddifferent dictators, it is experience and a firm
coinages that are an integral part of the languagegrasp of medical language and terminology that
of medicine. It is not feasible or expected for abecomes your number one tool for editing.
Medical Transcriptionist working in a fast-pacedWhen necessary, the transcriptionist may add
environment to convert the medical documentconjunctions, prepositions, articles, pronouns,
into a piece of formal writing or a polished essaynouns, and verbs to complete a sentence and
piece of writing.help make sense of sentences.
Medical Transcriptionists are expected to produceExamples:
clean, neat and accurate medical documents forPhysician dictates: No tenderness present over
every medical report dictated and to followchest
suggested or prescribed stylistic guidelinesTranscribed: No tenderness is present over the
common to the Medical Transcription field orchest.
according to the agency he or she works for.Physician dictates: Came in with chest pain
A lot of the stylistic rules of Medical TranscriptionTranscribed: The patient came in with chest pain.
relate to proper editing, punctuation, and grammar.It is also acceptable to type all of the above as
You will find that even the most respecteddictated. This preserves the style of the dictator.
reference materials vary and contradict oneIn my first job as a Medical Transcriptionist in a
another and themselves. The employer of asmall state run Crippled Children's Clinic, I was
Medical Transcriptionist may mandate specific rulesinstructed to type exactly what the physician
of grammar, style and format to be followed. Indictated. I only changed or edited sentences such
this case, the Medical Transcriptionist is required toas when doctor dictates throughout the report he
follow the styles and formats mandated by his oror she performed surgery on the left leg, and
her employer. In the absence of these, he or shethen suddenly changed it over to the right leg
can follow the common rules set forth bybefore the report was finished. And when I made
instructors of Medical Transcription and othersuch a change, I carefully read previous dictations
experienced Medical Transcriptionists.and diagnosis of patient to be certain which leg
Editingthe doctor actually performed surgery upon!
You will never find a perfect dictator! EveryThe Medical Transcriptionist should never edit
dictator has at one time or another misspoke andphysician dictation aggressively. It has to be done
said something like, "The patient smokes twosubtly, delicately and carefully. You want to
beers a day and drinks two packs," or refers toalways strive for a favorable response from the
surgery on the left arm in one paragraph anddictator. You need to be involved and alert while
surgery on the right arm in the next paragraph.transcribing medical dictation so that when
Busy dictating physicians count on the Medicalsomething is dictated that just does not make
Transcriptionist to be alert. When necessary, hesense, which does not flow, or does not add up,
or she must correct the mistakes of the dictatingyou will immediately detect it. Listen with an
physician. Most of the time you won't be requiredintelligent ear to produce accurate, intelligent, clear
to put coffee on and have a cup of coffeemedical documents. Keep in mind the fine line
waiting for the dictating physician, unless ofbetween "editing" and tampering.
course, you do this just out of courtesy, whichThis article is FREE to publish with the resource
can be nice, warm and friendly, when working inbox.