1. US HEALTHCARE

2. Objectives
 Know the Healthcare Industry and Process
 What is Medical Transcription?
 Medical Transcription Process
 Different types of Patients
 Different Providers
 Various Reports
 Skill Set to perform Medical Transcription
 Scope and Future of Medical Transcription

3. US HEALTHCARE PROCESS
Appointment Registration Financial Discussion Encounter
Billing Insurance
Claims AdjudicationPayment or No PaymentSettling of Patient’s Account
Collecting Balance from
Patient
Insurance

4. Brief
Take an appointment
Register oneself in Provider’s office and their software
Do a finance discussion for the payment
Meet the Provider for treatment
Generate Bill to be sent to Insurance
Let the bill be processed at the insurance end with the details sent
resulting in either payment or denial
Settling of the patient’s accounts as per the Insurance follow up
Balance billing to the patient
Collect balance amount and reschedule for next appointment

5. Medical Transcription:
Medical transcription is an allied health profession, which
deals in the process of converting pre recorded providers voice
files into text files/documents. These files after conversion are
called as transcribed reports or sheets.
VOICE FILE MEDICAL
TRANSCRIPTIONIST TRANSCRIBED SHEET /
MEDICAL RECORDS

6. Medical Transcription Process
When any patient visits a doctor, the latter spends time with the former
discussing his/her medical problems, including history and/or problems. The
doctor performs a physical examination and may request various laboratory or
diagnostic studies; will make a diagnosis or differential diagnoses, then decides
on a plan of treatment for the patient, which is discussed and explained to the
patient, with instructions provided. After the patient leaves the office, the doctor
uses a voice-recording device to record the information about the patient
encounter. This information may be recorded into a hand-held cassette
recorder or into a regular telephone, dialed into a central server located in the
hospital or transcription service office, which will 'hold' the report for the
transcriptionist. This report is then accessed by a medical transcriptionist. It is
received as a voice file or cassette recording. In turn the transcriptionist listens
to the dictation and transcribes it into the required format for the medical record,
and of which this medical record is considered a legal document. The next time
the patient visits the doctor, the doctor will call for the medical record or the
patient's entire chart, which will contain all reports from previous encounters.

7. Types of Patients:

8. Types of Physicians:

9. Types of Medical Reports (Major Ones):
History and Physical (H&P): This report is usually dictated by the admitting
physician or resident when a patient is admitted to the hospital. It usually
begins with a chief complaint. The “history” includes a history of the present
illness, past medical history, social history, and family medical history.
Smoking can go under the heading of either Social History or Habits. There is
usually a review of systems and a complete physical examination from head to
toe. The report usually ends with an admission diagnosis and a plan for the
patient’s treatment.
Consultation (Consult): This report is usually dictated by a physician to whom
the admitting physician has referred the patient. Therefore, the consulting
physician is usually a specialist in an area other than the admitting physician.
Sometimes consultations are requested for second opinions. Consultation
reports usually include a brief history of the patient’s illness and a specific
physical exam depending on the particular type of consultation requested. The
report may also include laboratory or x-ray findings. The report usually ends
with the consulting physician’s impression and plan, and sometimes a comment
from the consulting physician thanking the admitting physician for the referral.

10. Types Of Medical Reports (Major Ones) Contd…..
Operative Report(OP): This report is dictated by the operating physician and
contains detailed information regarding an operative procedure. Included in this
report are preoperative and postoperative diagnoses, the type of surgery or surgeries
that were performed, the names of the surgeon(s) and attending nursing staff, the
type of anesthesia and the name of the anesthesiologist, and a detailed description
of the operative procedure itself. Depending on the operative procedure, information
regarding instrument counts, sponge counts and blood loss are also dictated. Often
the report will end with disposition or where the patient was transferred when he left
the operating room (usually recovery room) and the condition of the patient at the
time of transfer.
Discharge Summary (DS): This report is dictated by the admitting physician at the
end of the patient’s stay in the hospital. It includes a summary of everything that
occurred from admission to discharge, including laboratory data, x-ray data, and
pertinent physical findings throughout the hospital course. The report usually ends
with the discharge diagnosis and a detailed plan for the patient. If the patient is
transferred to another institution (such as a nursing or other hospital), the name of
the report is usually changed from discharge summary to transfer summary. If the
patient has expired (died) during the hospital stay, the report is usually called a death
summary.

11. Types Of Medical Reports (Major Ones) Contd…..
Radiology Report: This report is dictated by the radiologist upon completion of a
diagnostic procedure and includes the radiologist’s findings and impression.
Examples of radiology reports are x-rays, CT scans, MRI scans, nuclear medicine
procedures and fluoroscopic studies.
Pathology Report: This report is dictated by a pathologist and describes findings of
a tissue sample. The focus of the report is on the microscopic findings and the
pathological diagnosis of the sample.
Laboratory Report: This report describes findings of examinations of bodily fluids
such as blood levels and urinalysis. Laboratory reports are rarely dictated separately
but are often included inside the H&P, consultation or discharge summary.
Miscellaneous Reports: Other miscellaneous hospital reports include cardiac
catheterizations, electrophysiology studies, phacoemulsification, autopsies and
psychological assessments.

12. SKILL SETS REQUIRED TO PEFORM MEDICAL TRANSCRIPTION
1. Strong English Grammar.
2. Compelling interest in the medical field.
3. Superior research skills.
4. Competent use of computer.
5. Keen listening skills.
6. Fine attention to details.
7. Commitment to lifelong learning.
8. Ability to sit and concentrate for long periods of time.

13. FUTURE AND SCOPE OF MEDICAL TRANSCRIPTION
• Bureau of Labor Statistics predicts a need for 5.3 million
healthcare workers.
• Supply not keeping up with demand.
• Aging population will put increasing pressure on the unprepared
healthcare system in US
FUTURE IS BRIGHT
- for professionals looking for a careers and not just a job.
- for professionals willing to commit to lifelong learning.
- for professionals willing to embrace standards and
credentialing

14. Thank You