What is medical transcription?

Medical transcription is the work of turning a clinician's recorded dictation into a written, formatted medical report. A medical transcriptionist listens to the recording and produces the medical report ¹. The clinician decides what is said. The transcriptionist's job is to render it accurately, in the right format, with the correct terms.

Transcription means turning recorded speech into text

Transcription, in general, is the process of writing down speech or music as text ². Medical transcription is the same process applied to a specific kind of speech: the dictation a physician or other healthcare worker records about a patient. The output is a document with a fixed structure, such as a history and physical, a discharge summary or an operative report.

The clinical setting is what makes the work specialized. Transcriptionists must know medical terminology, anatomy and physiology, and the rules of grammar ³. A word that sounds like another can change the meaning of a diagnosis or a drug, so accuracy matters more than speed.

The job has three parts: listening, formatting and checking

The work has three parts. First, the transcriptionist listens and types the dictation. Second, the transcriptionist applies the report format the facility uses. Third, the transcriptionist checks the finished draft. The Bureau of Labor Statistics says transcriptionists must assess medical reports and correct inaccuracies and inconsistencies in finished drafts ⁴.

Training programs cover the same ground. They typically include anatomy and physiology, medical terminology, the laws that relate to healthcare documentation, and English grammar and punctuation ⁵.

Speech recognition now drafts most of the text

Some employers now start from a machine draft. BLS lists reviewing and editing drafts prepared by speech recognition software among the usual duties of medical transcriptionists ⁶. For those employers, the work is correcting a draft more than typing a recording.

The draft still needs checking. In a study of clinical notes, 96.3 percent of the speech recognition drafts contained errors ⁷. That is why the editing step is central to the job. Our question on what a medical transcription editor does describes that review work in more detail.

It is not the same as dictation or medical scribing

Three related terms are easy to confuse:

The difference matters when you look for work. A transcriptionist works from a recording after the visit. A scribe works alongside the clinician, often in the room. Our question on the difference between a medical scribe and a medical transcriptionist sets out the contrast.

It depends on the setting and the report type

The answer depends on what is being transcribed. Hospital reports follow rules that set minimum content for some report types. For example, Medicare's hospital rules require an operative report to be written or dictated immediately after surgery and signed by the surgeon ⁸. Facilities add their own layouts, so the format of a consultation letter may differ from one hospital to the next. Our guide to medical transcription sets out the report types in more detail.

Medical transcription also differs from general transcription, such as recording a meeting or an interview. General transcription, such as an interview, does not need clinical terms or report layouts. If the recording contains patient information, check the rules with your employer before you use any tool that stores or processes it.

What to do if you want to learn the work

1. Learn the terms and the report formats. Start with the terminology and anatomy that programs teach ⁵.
2. Practice with real dictation. Our question on where to practice medical transcription lists sources with audio and completed transcripts.
3. Learn to check drafts. Because some employers now start from a machine draft, practice finding and fixing errors, not only typing.
4. Read the pay and outlook before you commit. Our question on how much medical transcriptionists make gives the official figures.

For the glossary terms used here, see the transcriptionist entry and the back-end speech recognition entry, which explains the workflow in which the software drafts first and an editor corrects afterwards.