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About Medical Transcription/Healthcare Documentation

MTs/HDSs: Partners in Patient Care Documentation

Healthcare documentation (formerly medical transcription) has existed since the beginning of medical care and research. Ancient cave writings attest to the earliest forms of healthcare documentation. While the medium changed from metal plates to clay tablets, from hieroglyphs on temple walls, to papyrus, to parchment, to paper, and most recently to electronic files, the reasons for maintaining records have always been the same: to record an individual’s health care and the achievements of medical science.

Until the twentieth century, physicians served both as providers of medical care and scribes for the medical community. After 1900, when standardization of medical data became critical to research, medical stenographers replaced physicians as scribes, taking their dictation in shorthand.

The advent of dictation equipment made it unnecessary for physician and scribe to work face-to-face, and the career of medical transcription was born. As physicians came to rely on the judgment and deductive reasoning of experienced medical transcriptionists to safeguard the accuracy and integrity of medical dictation, medical transcription evolved into a medical language specialty.


In the twenty-first century, many medical transcriptionists/healthcare documentation specialists are using speech recognition technology to help them create even more documents in a shorter time. Healthcare documentation is one of the most sophisticated of the allied health professions, creating an important partnership between healthcare providers and those who document patient care.


Healthcare Documentation As Professionals

Since 1978, medical transcriptionists (MTs)/healthcare documentation specialists (HDS) have been represented by a professional organization, the Association for Healthcare Documentation Integrity (AHDI), which has developed a competency profile (COMPRO®) and a model curriculum for transcription educators, as well as model job descriptions for transcriptionists and transcription-related positions. AHDI emphasizes continuing education for its members, holding an annual conference for medical transcriptionists, healthcare documentation specialists, educators, supervisors/managers, and business owners. There are component associations of AHDI, each of which holds regular meetings and symposia, around the U.S.

Through the efforts of AHDI, healthcare documentation specialists have become recognized as healthcare professionals and experts in the medical language.

What does a healthcare documentation specialist do?

In the broadest sense, medical transcription/healthcare documentation is the act of translating from oral to written form (on paper or electronically) the record of a person’s medical history, diagnosis, treatment, prognosis, and outcome.

The industry is moving toward electronic health records, allowing storage of an individual’s health history so that it can be accessed by physicians and other healthcare providers anywhere.

Physicians and other healthcare providers employ state-of-the-art electronic technology to dictate and transmit highly technical and confidential information about their patients. These medical professionals rely on skilled medical transcriptionists/healthcare documentation specialists to transform spoken words into comprehensive records that accurately communicate medical information. Speech recognition systems also may be used as an intermediary to translate the medical professional’s dictation into rough draft. The medical transcriptionist/healthcare documentation specialist further refines the draft into a finished document.

Keyboarding and documentation should not be confused. The primary skills necessary for performance of quality healthcare documentation are extensive medical knowledge and understanding, sound judgment, deductive reasoning, and the ability to detect medical inconsistencies in dictation. For example, a diagnosis inconsistent with the patient’s history and symptoms may be mistakenly dictated. The medical transcriptionist/healthcare documentation specialist questions, seeks clarification, verifies the information, and enters the correct information into the report.

What does a healthcare documentation specialist need to know?

Medical understanding is critical for the professional medical transcriptionist/healthcare documentation specialist. The complex terms used in medicine are unlike the language used in any other profession.

Healthcare documentation requires a practical knowledge of medical language relating to anatomy, physiology, disease processes, pharmacology, laboratory medicine, and the internal organization of medical reports. A healthcare documentation specialist is truly a medical language specialist who must be aware of standards and requirements that apply to the health record, as well as the legal significance of medical documentation.

Reports of patient care take many forms, including histories and physical examinations, progress reports, emergency room notes, consultations, operative reports, discharge summaries, clinic notes, referral letters, radiology reports, pathology reports, and an array of documentation spanning more than 60 medical specialties and frequently dictated by healthcare providers for whom English is a second language. Thus, the healthcare documentation specialist, or medical language specialist, must be well versed in the language of medicine.

How to prepare for this profession?

Healthcare documentation specialists study:

  • medical language, including: Greek and Latin suffixes, prefixes, and roots
  • biological science, including anatomy and physiology of all body systems, and various disease processes
  • medical science
  • medical and surgical procedures, including thousands of instruments, supplies, appliances, and prosthetic devices
  • pharmacology
  • laboratory values, correlating laboratory tests results with a patient’s symptoms and treatment
    diagnostic imaging procedures, including x-ray, ultrasound, MRI, CT, PET, and SPECT scans
  • use of medical reference materials and research techniques

Quality Healthcare Documentation Specialists

Quality medical transcription also requires:

  • above-average knowledge of English grammar and punctuation
  • excellent auditory skills, allowing the transcriptionist to interpret sounds almost simultaneously with keyboarding
  • advanced proofreading and editing skills, ensuring accuracy of transcribed material
  • versatility in use of transcription equipment and computers, since transcriptionists may work in a variety of settings
  • highly developed analytical skills, employing deductive reasoning to convert sounds into meaningful form

Why haven't I heard of this profession?

While medical transcription/healthcare documentation is among the most fascinating of the allied health professions, the general public knows little about those who practice this skill. It was not until 1999 that the U.S. Department of Labor assigned a separate job classification (Standard Occupational Classification #31-9094) so that statistics could be gathered on medical transcriptionists/healthcare documentation specialists. Prior to that, transcriptionists were misclassified as typists, word processors, medical secretaries, and dictating machine operators.

Through the efforts of AHDI, visibility and recognition for the profession have increased, and the terms medical transcriptionist, healthcare documentation specialist, and medical language specialist have gained widespread acceptance.

Healthcare documentation specialists work in settings that are usually far removed from the examining rooms, clinics, and hospital floors where health care is provided. Patients rarely have the opportunity to hear about those who transcribe their medical reports, and healthcare documentation specialists rarely meet the subjects of their work.

All healthcare providers rely to some extent on the skills of the healthcare documentation specialist to provide written documentation of health care. The reports produced by healthcare documentation specialists are the repository of information concerning medical practice. These reports function as legal documentation and fulfill requirements for insurance reimbursement. They also serve as reference for scientific research.

Healthcare documentation in the marketplace

Healthcare documentaiton specialists use their talents in a variety of healthcare settings, including doctors’ offices, public and private hospitals, teaching hospitals, medical schools, medical transcription businesses, clinics, laboratories, pathology and radiology departments, insurance companies, medical libraries, government medical facilities, rehabilitation centers, legal offices, research centers, veterinary medical facilities, and associations representing the healthcare industry.

Healthcare documentation specialists work with physicians and surgeons in multiple specialties. They work with pharmacists, therapists, technicians, nurses, dietitians, social workers, psychologists, and other medical personnel. All of these healthcare providers rely on information that is received, documented, and disseminated by the healthcare documentation specialist.

Qualified healthcare documentation specialists who wish to expand their professional responsibilities may become quality assurance specialists, editors, supervisors, managers, department heads, or owners of medical transcription businesses.

Experienced healthcare documentation specialists may become teachers, working in schools and colleges to educate future healthcare documentation professionals.

Healthcare documentation in the home

Some transcriptionists/healthcare documentation specialists choose to work from home as employees of transcription businesses or healthcare facilities. Still others provide service as independent contractors.

What about certification?

AHDI offers a level 1 credential, the RHDS (Registered Healthcare Documentation Specialist), and a level 2, advanced credential, the CHDS (Certified Healthcare Documentation Specialist). Both credentials are earned by passing an exam and are valid for 3 years. The RHDS credential is maintained by successful completion of a required online course, including a final exam, and payment of a renewal fee. The CHDS credentialed is maintained through continuing education.

Recent graduates of medical transcription/healthcare documentation education programs, MTs/HDSs with fewer than two years’ experience in acute care, and MTs/HDSs practicing in single-specialty areas are all eligible to take the RHDS exam. Healthcare documentation practitioners wishing to sit for the CHDS exam must have at least 2 years of acute-care experience.

Finally, it should be understood that all medical transcriptionists/healthcare documentation specialists share a common trait–enthusiasm for their profession.