Explore a Career in Medical Transcription (Self-Paced Tutorial) Online Certificate Course

Learn How To Transcribe The Most Common Medical Reports Used In Both Inpatient And Outpatient Settings

Explore a Career in Medical Transcription (Self-Paced Tutorial) Online Certificate Course

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Study Explore a Career in Medical Transcription Online Course and Learn How to Transcribe the Most Common Medical Reports Used in Both Inpatient and Outpatient Settings

In this course, you will learn how to transcribe the most common medical reports used in both inpatient and outpatient settings. This knowledge will help prepare you to work almost anywhere in the medical field—doctors' offices, clinics, public health facilities, and hospitals. With this foundation, you will be set to advance your education so you can work as a subcontractor for a company that outsources transcription, or you can eventually even take on your own clients—all from the comfort of your own home.

You will go through each of the nine main report types—their formatting requirements, the components of each one, and how they are used in the clinical setting. Every lesson will include a grammar review, pointing out important elements that will make your reports perfect. You will also gain important clinical knowledge of major disease processes that are essential to enhance your skill as a medical documentation specialist.
 
Along the way, you will download a free transcriber to listen to dictation and produce reports. These hands-on exercises will give you the practice you will need to determine if this field is for you. You will also go through your current options and in the future by developing the skills of a medical transcriptionist. By the end of this course, you will know the basic report types, have clinical knowledge of major diseases, be able to correct grammar from dictated reports on the fly, and know the next steps you will need to take!

What you will learn with our Explore a Career in Medical Transcription Online Course

  • Introduction to Medical Transcription
  • Tools of the Trade
  • Understanding Medical Records
  • Listening Carefully
  • Grammar, Sentence Structure, and Punctuation
  • Style
  • Medical Terminology and Spelling
  • Report Formatting and Word Processing
  • Checking Your Work
  • Classification Systems, and Discharge and Death Summaries
  • Infections, Blood, and Cells
  • The Nuts and Bolts of Working as an MT

Explore a Career in Medical Transcription Online Course - Requirements

The Explore a Career in Medical Transcription Course is delivered 100 percent online 24/7.

To successfully complete this course, a student must:

  • Have access to the internet and the necessary technical skills to navigate the online learning resources
  • Have access to any mobile device with internet connectivity (laptop, desktop, tablet)
  • Be a self-directed learner
  • Possess sound language and literacy skills

Quick Course Facts

  1. Course content is structured for easy comprehension
  2. Registered students gain unrestricted access to the Explore a Career in Medical Transcription Course
  3. All course material is available online 24/7 and can be accessed using any device
  4. Study online from anywhere in your own time at your own pace
  5. All students who complete the course will be awarded with a certificate of completion

For any additional questions please see our comprehensive FAQS tab above.

Explore a Career in Medical Transcription Online Course Outline

Lesson 1: Introduction to Medical Transcription

Chapter 1: Introduction

A medical transcriptionist (or MT, for short) is a word processor, medical terminology expert, ardent proofreader, grammar and spelling expert, occasionally a technology specialist, frequently a detective, and on rare occasions, even a mind reader! That last one is a bit of a joke, but you'll understand why MTs have to read between the lines on occasion.

Chapter 2: The History of Medical Transcription

Doctors have felt compelled to memorialize their practice since Hippocrates in the fourth century B.C. Doctors started collecting broad notes about what worked and didn't work for patients in various medical settings. Doctors typically keep these notes to themselves.

Topics to be discussed include:

  • Medical Transcription Today

Chapter 3: Where Do MTs Work?

MTs are most found in one of these three settings.

Topics to be discussed include:

  • The Future of Medical Transcription

Chapter 4: What Do You Need To Get Started?

Remember how I described my MT work in the first chapter? Didn't I make MTs sound well-rounded and sophisticated? We certainly are! Anyone could succeed in this field if all they had to do was listen and type. Let's go through a handful of the most important skills and abilities that make up a solid MT.

Topics to be discussed include:

  • Word Processing
  • Medical Terminology
  • Discretion and Tact
  • Proofreading
  • Detective Skills and ESP
  • Technology

Chapter 5: Conclusion

When someone asks, "What is a medical transcriptionist?" you should be able to give some solid responses. You can tell them that as an MT, you're much more than a fast typist... you're a tech-savvy word processor, proofreader, and grammar expert who also happens to have a vast knowledge of medical terminology and the tact and professionalism to understand the importance of keeping private patients' information private.

Lesson 2: Tools of the Trade

Chapter 1: Introduction

We'll start with the instruments of the trade used by MTs. First, we'll go over several reference books and talk about the many types of websites that MTs utilize for research. After that, we'll go over the hardware and software that today's MTs use on the job. It’ll walk you through the process of downloading the free software that we'll be using in this course, followed by a quick tour of how to utilize it.

Chapter 2: Reference Books

We'll start with the instruments of the trade used by MTs. First, we'll go over several reference books and talk about the many types of websites that MTs utilize for research. After that, we'll go over the hardware and software that today's MTs use on the job. It’ll walk you through the process of downloading the free software that we'll be using in this course, followed by a quick tour of how to utilize it.

Topics to be discussed include:

  • Online References and Medical Transcription Websites

Chapter 3: MT Equipment

We combed through the books and online materials used by MTs. Let's get started talking about the MT's most crucial tool: the computer.

Topics to be discussed include:

  • Working Comfortably
  • Software
  • Downloading Express Scribe

Chapter 4: Downloading and Opening Audio Files

Then, in Express Scribe, we'll need some audio to listen to. However, before downloading files from the Internet, it's a good idea to plan where you'll save them on your computer. So, first, create a folder on your desktop to save all of the audio files for this course.

Topics to be discussed include:

  • Short Keys

Chapter 5: Conclusion

First, we spoke about how important it is to have references on hand, whether they're books on your shelf or links in your computer (you'll get a chance to look at some of those websites in the Supplementary Material section of this session). After that, we talked about the devices and software you'll use to transcribe.

Lesson 3: Understanding Medical Records

Chapter 1: Introduction

Medical workers will prepare a range of detailed records to record every step of care when a patient visits a clinic or a hospital. This is true whether the visit is for major surgery, outpatient treatment, or a routine checkup, and whether the patient scheduled the appointment or showed up in the ER after an emergency.

Chapter 2: History and Physical Examination Report

An H&P, an admission report, or an admit report are all terms used to describe this report. Alternatively, it could be paired with a specific service, such as emergency services admittance report or internal medicine admit report, to indicate how the patient was admitted to the hospital. The H&P report covers everything you'd anticipate from the name, no matter how many versions there are.

Topics to be discussed include:

  • Discharge Summary Report
  • Radiology Report
  • Operative Report
  • Pathology Report
  • Consultation Report
  • Death Summary Report
  • Autopsy Report
  • The SOAP Note

Chapter 3: Medical Correspondence

Doctors send out a lot of letters to their patients. Some specialist doctors transcribe all of their chart notes to the primary doctor as a letter in the office, containing all of the features of a SOAP note but without the titles. This is commonly referred to as a narrative report.

Topics to be discussed include:

  • Parts of a Letter

Chapter 4: Practice Corner

We'll start with a general overview of pathology. Pathology is the study of body fluids and tissues to determine the disease process in a patient's body down to the cellular level. Pathologists, on the other hand, rarely encounter patients; instead, they examine a patient's fluid or tissue samples (visually and under a microscope) at the request of the patient's primary physician.

Topics to be discussed include:

  • Numbers
  • Measurements

Chapter 5: Conclusion

We looked at the objective and major features of eight separate hospital reports and one clinic report in this lesson, as well as examples of each one's unique layout. We also went over the major elements of a letter and some important points to remember while transcribing medical communication.

Lesson 4: Listening Carefully

Chapter 1: Introduction

The complexities of a medical professional's recorded words require human hearing and a profound grasp of syntax, medical terminology, and human anatomy and physiology. Because the English language is full of peculiarities, a person is required to complete the process.

Chapter 2: Active Listening

The MT's job revolves around language. It's all about patient care for doctors and other medical professionals. That's not to suggest they don't care about the reports you're being asked to transcribe; as we've established, these reports are an important aspect of a patient's care. Doctors, on the other hand, are unlikely to spend much time listening to their own dictations and wondering if you comprehend them.

Chapter 3: Homonyms, Synonyms, and Antonyms

Topics to be discussed include:

  • Homonyms
  • Similar Sounding Words
  • Synonyms
  • Antonyms
  • Phonetics and Vowel Sounds
  • Dealing With Imperfect Transcriptions

Chapter 4: Practice Corner

Radiology MTs are in high demand, but the sector appears to attract a large number of applicants, therefore employment rivalry is fierce. Knowing the procedures offered by a radiology department, the terminologies associated with those treatments, and the parts of the patient's body that may be affected is the greatest method to make oneself stand out. With the wide range of services provided by today's radiology departments.

Chapter 5: Conclusion

Most MTs are drawn to this field because they enjoy working with language—they enjoy putting words on paper and making sense of chaos. This lesson taught you a lot about words—words that can be swapped for others and words that can be confused with others.

Lesson 5: Grammar, Sentence Structure, and Punctuation

Chapter 1: Introduction

In this session, we'll cover several topics that may make you uncomfortable: grammar, sentence structure, and punctuation. Take a deep breath and relax before running away screaming. This will be a painless, if not fun, voyage through some basic writing ideas that will assist you in becoming a better MT.

Chapter 2: Grammar

For most of us, the subject of grammar conjures up a slew of unpleasant recollections. The good news is that most of your early grammatical lessons are still buried deep within your memory. To bring them out of hiding, all you need is a nice refresher.

Topics to be discussed include:

  • Sentence Structure
  • Modifiers
  • Subject-Verb Agreement

Chapter 3: Punctuation

Words, sentence structure, and spelling are all crucial, but punctuation is just as important. It has the power to completely alter the meaning of a phrase or statement.

Topics to be discussed include:

  • Period
  • Question Mark
  • Comma
  • Colons
  • Semicolon
  • Apostrophe
  • Compound Words and Hyphens
  • Using Punctuation to Provide Nuance

Chapter 4: Practice Corner

Your basic grammar abilities will be put to use in a variety of reports. In narrative reports, however, you'll rely on them the most. Narrative-heavy reports include correspondence, SOAP notes, H&P, and operative reports. Short reports, such as radiology and pathology reports, tend to rely more on formatting for the information delivered. In fact, one SOAP note will be included in the assignment.

Topics to be discussed include:

  • Medications, Pharmaceuticals, and Drugs
  • Laboratory Testing

Chapter 5: Summary

Your basic grammar abilities will be use in a variety of reports. In narrative reports, however, you'll rely on them the most. Narrative-heavy reports include correspondence, SOAP notes, H&P, and operative reports. Short reports, such as radiology and pathology reports, tend to rely more on formatting for the information delivered. In fact, one SOAP note will be included in the assignment.

Lesson 6: Style

Chapter 1: Introduction

Perhaps the word "style" conjures up images of the most recent fashion trends. Maybe it's the way writers put their words together if you're thinking in terms of writing style. Although both of these definitions of style are correct, it has a different meaning for MTs. You must respect editorial guidelines for spelling, capitalization, and typographical presentation when transcribing.

Chapter 2: Capitalization, Acronyms, and Initialisms

The capitalization rules used by MTs are designed to help you write clear and consistent reports. Take a look at these guidelines.

Topics to be discussed include:

  • Acronyms and Initialisms
  • Practice Time!
  • More Style Points
  • Years
  • Subscripts and Superscripts
  • Continued Pages

Chapter 3: Numbers

For MTs, numbers might be particularly challenging. Even if the rules that govern numbers appear random or foolish at first, I believe that once you look at a few examples, you'll see the wisdom in them. Let's look at some guidelines to help you figure out what to do with those baffling data.

Topics to be discussed include:

  • Ordinal Numbers

Chapter 4: Practice Corner

H&Ps are detailed reports on a patient's current health status, as well as a review of their medical history. As a result, the report normally has a lot of components, each of which needs to be separated into its own section to make it easier to read. Anyone can skim the report for specific information and, if necessary, find it fast.

Topics to be discussed include:

  • Formatting

Chapter 5: Summary

The most crucial thing to keep in mind is to stick to your style manuals. A good style reference, such as the Book of Style for Medical Transcription, will assist you decide whether to capitalize a term or whether to use an Arabic or Roman numeral.

Lesson 7: Medical Terminology and Spelling

Chapter 1: Introduction

Whatever you're transcribing, one thing is certain: medical terminology will play a significant role. I can't think of any profession with such a large vocabulary, and becoming familiar with all of those words and knowing how to spell them is an important part of the learning process for MTs.

Chapter 2: Understanding Medical Terminology

The reason for this is that thousands of terms we use today have foreign origins, the majority of which are Greek and Latin. In reality, you could acquire the majority of modern-day English by memorizing only 300 basic Greek and Latin word constituents.

Topics to be discussed include:

  • Root Words
  • Prefixes 
  • Suffixes 
  • Combining Words

Chapter 3: Spelling

The English language's spelling conventions frequently defy logic. And just when you think you've memorized the rules, you'll come upon an exception. Even so, having a rudimentary mastery of the fundamental laws of spelling is beneficial.

Topics to be discussed include:

  • Cardiology
  • Respiratory
  • Gastroenterology
  • OB/Gyn
  • Radiology
  • Surgery
  • Spelling Checkers

Chapter 4: Practice Corner

There are a few typical disease processes that you should be aware of since they entail transcription difficulties.

Topics to be discussed include:

  • Diabetes

Chapter 5: Summary

We also covered some information on heart disease and diabetes, two major conditions to which you'll be exposed a lot when transcribing. The more you know about common ailments, the easier it will be to transcribe the reports that go along with them.

Lesson 8: Report Formatting and Word Processing

Chapter 1: Introduction

We'll talk about how you put your reports together in this class. When you transcribe a report, it isn't just a straight narrative like when you transcribe a chapter in a book. Headings, subheadings, specific line spacing, page breaks, and other formatting refinements will nearly always be used to divide your reports into sections.

Chapter 2: Report Formatting

The American Society for Testing and Materials (ASTM) has published a study titled Standard Specifications for Healthcare Document Formats. ASTM outlines a standard structure for healthcare reports in this document, and institutions and organizations are free to use the details in their own industry. This enables healthcare institutions to report in a consistent manner.

Topics to be discussed include:

  • Report Formatting Guidelines
  • Margins
  • Paragraph Breaks and Page Endings
  • Headings

Chapter 3: Shortcuts, AutoText, Macros, and Templates

It's easy to learn how to use one of the other programs if you're already familiar with one. Furthermore, regardless of the word processing program your employers use, a solid understanding of any word processing application will be advantageous. Spend some time familiarizing yourself with your word processing program's Help menu.

Topics to be discussed include:

  • Keyboard Shortcuts
  • CTRL Key Combinations
  • AutoText 
  • Macros
  • Templates

Chapter 4: Practice Corner

This Practice Corner will be devoted to surgical reports. Before attempting to transcribe these types of reports, you need be familiar with key phrases that are used specifically in surgical procedures. While working on surgical reports, you'll want to keep your medical vocabulary handy, but there are some things you won't find in a dictionary.

Topics to be discussed include:

  • Positions
  • Anesthesia
  • Instruments
  • Incisions
  • Suture Material
  • Wound Closure
  • Drains

Chapter 5: Summary

There's a lot more to medical transcription than meets the eye, as you're probably beginning to realize. We must not only be careful in how we construct our reports, but we must also get familiar with a wide range of medical terminology. Fortunately, we have some excellent tools at our disposal to assist us in our efforts.

Lesson 9: Checking Your Work

Chapter 1: Introduction

You've studied how to put your reports together in terms of style, grammar, spelling, and formatting in our previous sessions. But there's one more stage to transcription that's crucial: editing and proofreading your work. This phase is equally as crucial as the others because it's your final chance to polish your work to perfection before turning it in.

Chapter 2: Editing on the Fly

It can be difficult to edit medical transcription. Choosing when you can edit on your own versus when you should notify the dictator will be one of your main worries. Some errors are obvious and easily corrected, while others are less so. There's also everything in between. It takes diplomacy to edit dictation that is confusing or inconsistent.

Topics to be discussed include:

  • Editing Techniques
  • Editing Do's
  • Editing Don'ts
  • Proofreading Marks

Chapter 3: Dealing With Incomplete or Imperfect Transcriptions

For an MT, nothing is more aggravating than an inadequate transcription. You'll learn that you're willing to go to great lengths to figure out what a jumbled phrase or word really means. Slips that need to be returned to the dictator for clarification, such as conflicts between references to right and left, will frustrate you.

Topics to be discussed include:

  • Tricks of the Trade
  • When in Doubt
  • Final Tips
  • Practice Corner
  • Metastasis

Chapter 4: Transcription Issues for Cancer

The majority of consultations are conducted by specialists. If a general practitioner (GP) has a patient with symptoms that may signal the need for surgery, the GP may refer the patient to a surgeon for a consultation. The specialist will assess the patient, perform any necessary testing, and maybe perform surgery before returning to the GP with a written report (or numerous reports).

Topics to be discussed include:

  • Grading and Staging
  • Dukes Classification
  • TNM Staging System

Chapter 5: Summary

Cancer is a depressing subject. However, it is a fascinating subject of labor from the perspective of the transcriptionist. Furthermore, it is becoming increasingly hopeful.

Lesson 10: Classification Systems, and Discharge and Death Summaries

Chapter 1: Introduction

We're going to take a new approach in this lesson. So far, we've concentrated on the mechanical aspects of medical transcribing. However, there is still a lot to learn about clinical difficulties. As a result, we'll have a clinical lesson. We discussed cancer classification systems in our previous session, but there are other classification systems as well.

Chapter 2: A Few Classification Systems

We'll start with several typical classification systems, such as Apgar, burns, and ulcers. These are classifications that you'll probably hear a lot while transcribing, therefore we should spend some time memorizing them.

Topics to be discussed include:

  • Apgar
  • Burns
  • Ulcers

Chapter 3: Bones

Many of the papers we've gone over in this course are required for transcription for an orthopedist. General chart notes, H&Ps, consultations, discharge summaries, and surgery reports can all be dictated by orthopedists. But, above all, you must understand bones.

Topics to be discussed include:

  • Arthritis
  • The Spine
  • Orthopedic Classifications

Chapter 4: Practice Corner

Let's take a closer look at each of these reports because they might be rather lengthy. Typically, the discharge report would include a lot of information about IV fluids. Because you won't hear this word in most other reports, I'd want to explain it to you.

Topics to be discussed include:

  • Discharge Summary Report
  • Intravenous Fluids
  • Death Summary Report

Chapter 5: Summary

We basically spoke about classification systems, bones, and discharge and death reports in this course. You learnt about Apgar, burns, and ulcers, which are three of the most frequent classification systems. The discussion then moved on to bones and the many transcribing challenges that they provide. You'll hear a lot about arthritis, vertebrae, and numerous orthopedic classifications throughout your transcription work.

Lesson 11: Infections, Blood, and Cells

Chapter 1: Introduction

We'll return to clinical issues once we've finished with these random topics. Infections will be discussed in Chapter 3. Then we'll look at cells and blood, which are tiny elements of the body. Then you'll see how everything you've learned can be put together in an autopsy report in our Practice Corner. This is most likely the longest and most thorough study you'll ever read.

Chapter 2: Miscellaneous Transcription Issues

Medical transcription encompasses a large amount of data that doesn't necessarily lend itself to classification. As a result, this will be a useful lesson to repeat from time to time to help you remember some of the finer points.

Topics to be discussed include:

  • Status Post
  • Nonspecific Dates
  • Another Capitalization Point
  • "Dictated but Not read" or "Transcribed but Not read"
  • Made-up Words

Chapter 3: Infections, Blood, and Tissues

Let's continue our clinical conversation by talking about infections and their transmission channels. You've already learned how to write the names of the viruses and bacteria that cause diseases, but there are some interesting aspects about how infections spread and take hold that you should know about.

Topics to be discussed include:

  • Infection Routes of Transmission
  • Blood
  • Tissues

Chapter 4: Practice Corner

We'll be looking at the autopsy report in this Practice Corner. The autopsy report is normally in three sections and is quite long and detailed.

Chapter 5: Summary

Didn't we cover a lot of ground today? In this session, you learned that medical transcription requires a great deal of attention to detail. Some things don't fit neatly into any of the categories, and those are the ones we talked about.

Lesson 12: The Nuts and Bolts of Working as an MT

Chapter 1: Introduction

It's an exciting time to enter the transcription field, but it's also a little frightening. We're about to undergo a massive transformation in terms of our organization, how we work, and how we'll be able to apply our expertise. The introduction of the electronic medical record (EMR) is the catalyst for this shift.

Chapter 2: Priorities and Workloads

Let's start by talking about how you'll be working. You must not only properly transcribe reports, but you must also prioritize the order in which you transcribe them.

Topics to be discussed include:

  • Turnaround Times
  • Speech Recognition and the EHR

Chapter 3: Employment and Certification Possibilities

MTs develop a wide range of talents, as you've seen throughout the course. Simply having medical terminology in your MT toolkit will make you a valued commodity. As a result, you can work in a variety of healthcare settings. Take a look at a few of the choices to get a sense of what's available to you.

Topics to be discussed include:

  • Independent Contractor
  • Private Practice
  • Additional Responsibilities in Private Practice
  • Large Contractor
  • Additional Duties of the Owner of an MT Organization
  • Consultant
  • Additional Training and Certification

Chapter 4: Practice Corner: The Health Story Project

The Health Story Project began as a project dubbed CDA4CDT (Clinical Document Architecture for Clinical Data Types), which stands for Clinical Document Architecture for Clinical Data Types. Its goal was to develop clinical document standards that would interact with electronic health records. It was essentially to ensure that all EHR firms could use the same set of regulations for document creation and storage.

Chapter 5: Summary

There are even topics to learn about which we are unaware of. That is what makes this field so intriguing right now. This is a career for you if you're the type of person that enjoys continuing to learn and progress. And if you have the ability to look into the future in addition to being a language specialist and a mind reader, there is a position for you in guiding this field into that future.

Recognition & Accreditation

All students who complete the course receive a certificate of completion with a passing score (for the online assessment) and will be issued a certificate via email.

There are 12 units of study

Introduction to Medical Transcription

This first lesson looks at the history of medical transcription as a career. You will find out how the field has evolved into its modern form, and you will explore the various skills and aptitudes that you will need to succeed as a professional medical transcriptionist. You will examine the type of work MTs produce, where you might work, and what might be in store for those working in this career field.     

Tools of the Trade

This lesson focuses on the tools of the trade. You will review a few of the reference books and discuss the types of Web sites that MTs use for research. Then you will learn about the hardware and software that today's MTs use on the job. By the end of this lesson, you will be sitting at your computer, listening to a real medical dictation audio file and looking at the Express Scribe software on your screen. As you listen to the medical report, you will practice starting, pausing, and rewinding the audio as you tap away on the keyboard.      

Understanding Medical Records

There are nine report types that medical professionals use most often in both hospitals and clinics. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, you might need a refresher. You will finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then you will practice transcribing a medical letter and a pathology report.         

Listening Carefully

This lesson goes over how to listen most effectively, discussing the difference between hearing and active listening. You will also touch on many of the issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. You will learn how to use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Next, you will learn about radiology reports and finish up by practicing transcribing one.       

Grammar, Sentence Structure, and Punctuation

This lesson covers some subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better MT. Then, in your Practice Corner, you will learn about SOAP notes and then turn your attention to infectious diseases and medications. You will also have the chance to transcribe a SOAP note and a radiology report in the assignment that accompanies the lesson.

Style

This lesson explores writing and talks about style from the MT's perspective. When you're transcribing, you must follow editorial directions in spelling, capitalization, and typographical display. And it's those directions that are the style MTs need to be concerned about. You may be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercased? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? Finally, in your Practice Corner, you will focus on the H&P report and practice transcribing one.    

Medical Terminology and Spelling

No matter what you transcribe, one thing is a given: Medical terminology will be a huge part of it. One thing to remember is that dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like cystitome and cystotome. If you have a good understanding of medical terminology, you can pinpoint the correct word to make sure your transcription is accurate. Then, in your Practice Corner, you will review the basic nature of heart disease and its treatment.         

Report Formatting and Word Processing

A critical component of the MT's work is the way you put your reports together. This lesson focuses on breaking your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. You will also take a closer look at ways to make your work easier with word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient MT! Today’s Practice Corner focuses on surgical reports. Surgical terminology is important to know, and it's also fascinating to take an inside look at what goes on in the operating room.

Checking Your Work

Another essential step in transcription is editing and proofreading your work. This lesson starts off with editing do's and don'ts, as well as what to look for when you're proofreading. In your Practice Corner, you will be covering a disease process that has, in some way, touched virtually everyone: cancer. Once you have an overview of cancer, you will work on the consultation report. Physicians often ask specialists to further evaluate their patients, especially cancer patients. So, this is a common report that you're likely to transcribe regularly. The assignment for this lesson includes a consult report to transcribe, and you will also get to practice proofreading.     

Classification Systems, and Discharge and Death Summaries

This will be a completely clinical lesson. You will learn about classification systems and their transcription foibles. And now that you have the bones of grammar and style down, you will learn about real bones. Finally, in your Practice Corner, you will learn about discharge and death summaries. They are very similar reports, but this lesson explains the subtle differences.        

Infections, Blood, and Cells

This lesson will be similar to the last in that it covers lots of clinical issues. It won't all be clinical, however. In your Practice Corner, you will see how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you will ever come across. And, of course, you will have the chance to transcribe an autopsy report in the assignment!

The Nuts and Bolts of Working as an MT

By now you have the tools and the knowledge you need to dip your toe into the waters of medical transcription. But we still have a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist? And do you need more training?

Entry requirements

Students must have basic literacy and numeracy skills.

Minimum education

Open entry. Previous schooling and academic achievements are not required for entry into this course.

Computer requirements

Students will need access to a computer and the internet.

Minimum specifications for the computer are:

Windows:

  • Microsoft Windows XP, or later
  • Modern and up to date Browser (Internet Explorer 8 or later, Firefox, Chrome)

All systems

  • Internet bandwidth of 1Mb or faster
  • Flash player or a browser with HTML5 video capabilities(Currently Internet Explorer 9, Firefox, Chrome)

Students will also need access the following applications:

Adobe Acrobat Reader

Note: This course is not suitable for Macintosh users.

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About this Course

Study Explore a Career in Medical Transcription Online Course and Learn How to Transcribe the Most Common Medical Reports Used in Both Inpatient and Outpatient Settings

In this course, you will learn how to transcribe the most common medical reports used in both inpatient and outpatient settings. This knowledge will help prepare you to work almost anywhere in the medical field—doctors' offices, clinics, public health facilities, and hospitals. With this foundation, you will be set to advance your education so you can work as a subcontractor for a company that outsources transcription, or you can eventually even take on your own clients—all from the comfort of your own home.

You will go through each of the nine main report types—their formatting requirements, the components of each one, and how they are used in the clinical setting. Every lesson will include a grammar review, pointing out important elements that will make your reports perfect. You will also gain important clinical knowledge of major disease processes that are essential to enhance your skill as a medical documentation specialist.
 
Along the way, you will download a free transcriber to listen to dictation and produce reports. These hands-on exercises will give you the practice you will need to determine if this field is for you. You will also go through your current options and in the future by developing the skills of a medical transcriptionist. By the end of this course, you will know the basic report types, have clinical knowledge of major diseases, be able to correct grammar from dictated reports on the fly, and know the next steps you will need to take!

What you will learn with our Explore a Career in Medical Transcription Online Course

  • Introduction to Medical Transcription
  • Tools of the Trade
  • Understanding Medical Records
  • Listening Carefully
  • Grammar, Sentence Structure, and Punctuation
  • Style
  • Medical Terminology and Spelling
  • Report Formatting and Word Processing
  • Checking Your Work
  • Classification Systems, and Discharge and Death Summaries
  • Infections, Blood, and Cells
  • The Nuts and Bolts of Working as an MT

Explore a Career in Medical Transcription Online Course - Requirements

The Explore a Career in Medical Transcription Course is delivered 100 percent online 24/7.

To successfully complete this course, a student must:

  • Have access to the internet and the necessary technical skills to navigate the online learning resources
  • Have access to any mobile device with internet connectivity (laptop, desktop, tablet)
  • Be a self-directed learner
  • Possess sound language and literacy skills

Quick Course Facts

  1. Course content is structured for easy comprehension
  2. Registered students gain unrestricted access to the Explore a Career in Medical Transcription Course
  3. All course material is available online 24/7 and can be accessed using any device
  4. Study online from anywhere in your own time at your own pace
  5. All students who complete the course will be awarded with a certificate of completion

For any additional questions please see our comprehensive FAQS tab above.

Explore a Career in Medical Transcription Online Course Outline

Lesson 1: Introduction to Medical Transcription

Chapter 1: Introduction

A medical transcriptionist (or MT, for short) is a word processor, medical terminology expert, ardent proofreader, grammar and spelling expert, occasionally a technology specialist, frequently a detective, and on rare occasions, even a mind reader! That last one is a bit of a joke, but you'll understand why MTs have to read between the lines on occasion.

Chapter 2: The History of Medical Transcription

Doctors have felt compelled to memorialize their practice since Hippocrates in the fourth century B.C. Doctors started collecting broad notes about what worked and didn't work for patients in various medical settings. Doctors typically keep these notes to themselves.

Topics to be discussed include:

  • Medical Transcription Today

Chapter 3: Where Do MTs Work?

MTs are most found in one of these three settings.

Topics to be discussed include:

  • The Future of Medical Transcription

Chapter 4: What Do You Need To Get Started?

Remember how I described my MT work in the first chapter? Didn't I make MTs sound well-rounded and sophisticated? We certainly are! Anyone could succeed in this field if all they had to do was listen and type. Let's go through a handful of the most important skills and abilities that make up a solid MT.

Topics to be discussed include:

  • Word Processing
  • Medical Terminology
  • Discretion and Tact
  • Proofreading
  • Detective Skills and ESP
  • Technology

Chapter 5: Conclusion

When someone asks, "What is a medical transcriptionist?" you should be able to give some solid responses. You can tell them that as an MT, you're much more than a fast typist... you're a tech-savvy word processor, proofreader, and grammar expert who also happens to have a vast knowledge of medical terminology and the tact and professionalism to understand the importance of keeping private patients' information private.

Lesson 2: Tools of the Trade

Chapter 1: Introduction

We'll start with the instruments of the trade used by MTs. First, we'll go over several reference books and talk about the many types of websites that MTs utilize for research. After that, we'll go over the hardware and software that today's MTs use on the job. It’ll walk you through the process of downloading the free software that we'll be using in this course, followed by a quick tour of how to utilize it.

Chapter 2: Reference Books

We'll start with the instruments of the trade used by MTs. First, we'll go over several reference books and talk about the many types of websites that MTs utilize for research. After that, we'll go over the hardware and software that today's MTs use on the job. It’ll walk you through the process of downloading the free software that we'll be using in this course, followed by a quick tour of how to utilize it.

Topics to be discussed include:

  • Online References and Medical Transcription Websites

Chapter 3: MT Equipment

We combed through the books and online materials used by MTs. Let's get started talking about the MT's most crucial tool: the computer.

Topics to be discussed include:

  • Working Comfortably
  • Software
  • Downloading Express Scribe

Chapter 4: Downloading and Opening Audio Files

Then, in Express Scribe, we'll need some audio to listen to. However, before downloading files from the Internet, it's a good idea to plan where you'll save them on your computer. So, first, create a folder on your desktop to save all of the audio files for this course.

Topics to be discussed include:

  • Short Keys

Chapter 5: Conclusion

First, we spoke about how important it is to have references on hand, whether they're books on your shelf or links in your computer (you'll get a chance to look at some of those websites in the Supplementary Material section of this session). After that, we talked about the devices and software you'll use to transcribe.

Lesson 3: Understanding Medical Records

Chapter 1: Introduction

Medical workers will prepare a range of detailed records to record every step of care when a patient visits a clinic or a hospital. This is true whether the visit is for major surgery, outpatient treatment, or a routine checkup, and whether the patient scheduled the appointment or showed up in the ER after an emergency.

Chapter 2: History and Physical Examination Report

An H&P, an admission report, or an admit report are all terms used to describe this report. Alternatively, it could be paired with a specific service, such as emergency services admittance report or internal medicine admit report, to indicate how the patient was admitted to the hospital. The H&P report covers everything you'd anticipate from the name, no matter how many versions there are.

Topics to be discussed include:

  • Discharge Summary Report
  • Radiology Report
  • Operative Report
  • Pathology Report
  • Consultation Report
  • Death Summary Report
  • Autopsy Report
  • The SOAP Note

Chapter 3: Medical Correspondence

Doctors send out a lot of letters to their patients. Some specialist doctors transcribe all of their chart notes to the primary doctor as a letter in the office, containing all of the features of a SOAP note but without the titles. This is commonly referred to as a narrative report.

Topics to be discussed include:

  • Parts of a Letter

Chapter 4: Practice Corner

We'll start with a general overview of pathology. Pathology is the study of body fluids and tissues to determine the disease process in a patient's body down to the cellular level. Pathologists, on the other hand, rarely encounter patients; instead, they examine a patient's fluid or tissue samples (visually and under a microscope) at the request of the patient's primary physician.

Topics to be discussed include:

  • Numbers
  • Measurements

Chapter 5: Conclusion

We looked at the objective and major features of eight separate hospital reports and one clinic report in this lesson, as well as examples of each one's unique layout. We also went over the major elements of a letter and some important points to remember while transcribing medical communication.

Lesson 4: Listening Carefully

Chapter 1: Introduction

The complexities of a medical professional's recorded words require human hearing and a profound grasp of syntax, medical terminology, and human anatomy and physiology. Because the English language is full of peculiarities, a person is required to complete the process.

Chapter 2: Active Listening

The MT's job revolves around language. It's all about patient care for doctors and other medical professionals. That's not to suggest they don't care about the reports you're being asked to transcribe; as we've established, these reports are an important aspect of a patient's care. Doctors, on the other hand, are unlikely to spend much time listening to their own dictations and wondering if you comprehend them.

Chapter 3: Homonyms, Synonyms, and Antonyms

Topics to be discussed include:

  • Homonyms
  • Similar Sounding Words
  • Synonyms
  • Antonyms
  • Phonetics and Vowel Sounds
  • Dealing With Imperfect Transcriptions

Chapter 4: Practice Corner

Radiology MTs are in high demand, but the sector appears to attract a large number of applicants, therefore employment rivalry is fierce. Knowing the procedures offered by a radiology department, the terminologies associated with those treatments, and the parts of the patient's body that may be affected is the greatest method to make oneself stand out. With the wide range of services provided by today's radiology departments.

Chapter 5: Conclusion

Most MTs are drawn to this field because they enjoy working with language—they enjoy putting words on paper and making sense of chaos. This lesson taught you a lot about words—words that can be swapped for others and words that can be confused with others.

Lesson 5: Grammar, Sentence Structure, and Punctuation

Chapter 1: Introduction

In this session, we'll cover several topics that may make you uncomfortable: grammar, sentence structure, and punctuation. Take a deep breath and relax before running away screaming. This will be a painless, if not fun, voyage through some basic writing ideas that will assist you in becoming a better MT.

Chapter 2: Grammar

For most of us, the subject of grammar conjures up a slew of unpleasant recollections. The good news is that most of your early grammatical lessons are still buried deep within your memory. To bring them out of hiding, all you need is a nice refresher.

Topics to be discussed include:

  • Sentence Structure
  • Modifiers
  • Subject-Verb Agreement

Chapter 3: Punctuation

Words, sentence structure, and spelling are all crucial, but punctuation is just as important. It has the power to completely alter the meaning of a phrase or statement.

Topics to be discussed include:

  • Period
  • Question Mark
  • Comma
  • Colons
  • Semicolon
  • Apostrophe
  • Compound Words and Hyphens
  • Using Punctuation to Provide Nuance

Chapter 4: Practice Corner

Your basic grammar abilities will be put to use in a variety of reports. In narrative reports, however, you'll rely on them the most. Narrative-heavy reports include correspondence, SOAP notes, H&P, and operative reports. Short reports, such as radiology and pathology reports, tend to rely more on formatting for the information delivered. In fact, one SOAP note will be included in the assignment.

Topics to be discussed include:

  • Medications, Pharmaceuticals, and Drugs
  • Laboratory Testing

Chapter 5: Summary

Your basic grammar abilities will be use in a variety of reports. In narrative reports, however, you'll rely on them the most. Narrative-heavy reports include correspondence, SOAP notes, H&P, and operative reports. Short reports, such as radiology and pathology reports, tend to rely more on formatting for the information delivered. In fact, one SOAP note will be included in the assignment.

Lesson 6: Style

Chapter 1: Introduction

Perhaps the word "style" conjures up images of the most recent fashion trends. Maybe it's the way writers put their words together if you're thinking in terms of writing style. Although both of these definitions of style are correct, it has a different meaning for MTs. You must respect editorial guidelines for spelling, capitalization, and typographical presentation when transcribing.

Chapter 2: Capitalization, Acronyms, and Initialisms

The capitalization rules used by MTs are designed to help you write clear and consistent reports. Take a look at these guidelines.

Topics to be discussed include:

  • Acronyms and Initialisms
  • Practice Time!
  • More Style Points
  • Years
  • Subscripts and Superscripts
  • Continued Pages

Chapter 3: Numbers

For MTs, numbers might be particularly challenging. Even if the rules that govern numbers appear random or foolish at first, I believe that once you look at a few examples, you'll see the wisdom in them. Let's look at some guidelines to help you figure out what to do with those baffling data.

Topics to be discussed include:

  • Ordinal Numbers

Chapter 4: Practice Corner

H&Ps are detailed reports on a patient's current health status, as well as a review of their medical history. As a result, the report normally has a lot of components, each of which needs to be separated into its own section to make it easier to read. Anyone can skim the report for specific information and, if necessary, find it fast.

Topics to be discussed include:

  • Formatting

Chapter 5: Summary

The most crucial thing to keep in mind is to stick to your style manuals. A good style reference, such as the Book of Style for Medical Transcription, will assist you decide whether to capitalize a term or whether to use an Arabic or Roman numeral.

Lesson 7: Medical Terminology and Spelling

Chapter 1: Introduction

Whatever you're transcribing, one thing is certain: medical terminology will play a significant role. I can't think of any profession with such a large vocabulary, and becoming familiar with all of those words and knowing how to spell them is an important part of the learning process for MTs.

Chapter 2: Understanding Medical Terminology

The reason for this is that thousands of terms we use today have foreign origins, the majority of which are Greek and Latin. In reality, you could acquire the majority of modern-day English by memorizing only 300 basic Greek and Latin word constituents.

Topics to be discussed include:

  • Root Words
  • Prefixes 
  • Suffixes 
  • Combining Words

Chapter 3: Spelling

The English language's spelling conventions frequently defy logic. And just when you think you've memorized the rules, you'll come upon an exception. Even so, having a rudimentary mastery of the fundamental laws of spelling is beneficial.

Topics to be discussed include:

  • Cardiology
  • Respiratory
  • Gastroenterology
  • OB/Gyn
  • Radiology
  • Surgery
  • Spelling Checkers

Chapter 4: Practice Corner

There are a few typical disease processes that you should be aware of since they entail transcription difficulties.

Topics to be discussed include:

  • Diabetes

Chapter 5: Summary

We also covered some information on heart disease and diabetes, two major conditions to which you'll be exposed a lot when transcribing. The more you know about common ailments, the easier it will be to transcribe the reports that go along with them.

Lesson 8: Report Formatting and Word Processing

Chapter 1: Introduction

We'll talk about how you put your reports together in this class. When you transcribe a report, it isn't just a straight narrative like when you transcribe a chapter in a book. Headings, subheadings, specific line spacing, page breaks, and other formatting refinements will nearly always be used to divide your reports into sections.

Chapter 2: Report Formatting

The American Society for Testing and Materials (ASTM) has published a study titled Standard Specifications for Healthcare Document Formats. ASTM outlines a standard structure for healthcare reports in this document, and institutions and organizations are free to use the details in their own industry. This enables healthcare institutions to report in a consistent manner.

Topics to be discussed include:

  • Report Formatting Guidelines
  • Margins
  • Paragraph Breaks and Page Endings
  • Headings

Chapter 3: Shortcuts, AutoText, Macros, and Templates

It's easy to learn how to use one of the other programs if you're already familiar with one. Furthermore, regardless of the word processing program your employers use, a solid understanding of any word processing application will be advantageous. Spend some time familiarizing yourself with your word processing program's Help menu.

Topics to be discussed include:

  • Keyboard Shortcuts
  • CTRL Key Combinations
  • AutoText 
  • Macros
  • Templates

Chapter 4: Practice Corner

This Practice Corner will be devoted to surgical reports. Before attempting to transcribe these types of reports, you need be familiar with key phrases that are used specifically in surgical procedures. While working on surgical reports, you'll want to keep your medical vocabulary handy, but there are some things you won't find in a dictionary.

Topics to be discussed include:

  • Positions
  • Anesthesia
  • Instruments
  • Incisions
  • Suture Material
  • Wound Closure
  • Drains

Chapter 5: Summary

There's a lot more to medical transcription than meets the eye, as you're probably beginning to realize. We must not only be careful in how we construct our reports, but we must also get familiar with a wide range of medical terminology. Fortunately, we have some excellent tools at our disposal to assist us in our efforts.

Lesson 9: Checking Your Work

Chapter 1: Introduction

You've studied how to put your reports together in terms of style, grammar, spelling, and formatting in our previous sessions. But there's one more stage to transcription that's crucial: editing and proofreading your work. This phase is equally as crucial as the others because it's your final chance to polish your work to perfection before turning it in.

Chapter 2: Editing on the Fly

It can be difficult to edit medical transcription. Choosing when you can edit on your own versus when you should notify the dictator will be one of your main worries. Some errors are obvious and easily corrected, while others are less so. There's also everything in between. It takes diplomacy to edit dictation that is confusing or inconsistent.

Topics to be discussed include:

  • Editing Techniques
  • Editing Do's
  • Editing Don'ts
  • Proofreading Marks

Chapter 3: Dealing With Incomplete or Imperfect Transcriptions

For an MT, nothing is more aggravating than an inadequate transcription. You'll learn that you're willing to go to great lengths to figure out what a jumbled phrase or word really means. Slips that need to be returned to the dictator for clarification, such as conflicts between references to right and left, will frustrate you.

Topics to be discussed include:

  • Tricks of the Trade
  • When in Doubt
  • Final Tips
  • Practice Corner
  • Metastasis

Chapter 4: Transcription Issues for Cancer

The majority of consultations are conducted by specialists. If a general practitioner (GP) has a patient with symptoms that may signal the need for surgery, the GP may refer the patient to a surgeon for a consultation. The specialist will assess the patient, perform any necessary testing, and maybe perform surgery before returning to the GP with a written report (or numerous reports).

Topics to be discussed include:

  • Grading and Staging
  • Dukes Classification
  • TNM Staging System

Chapter 5: Summary

Cancer is a depressing subject. However, it is a fascinating subject of labor from the perspective of the transcriptionist. Furthermore, it is becoming increasingly hopeful.

Lesson 10: Classification Systems, and Discharge and Death Summaries

Chapter 1: Introduction

We're going to take a new approach in this lesson. So far, we've concentrated on the mechanical aspects of medical transcribing. However, there is still a lot to learn about clinical difficulties. As a result, we'll have a clinical lesson. We discussed cancer classification systems in our previous session, but there are other classification systems as well.

Chapter 2: A Few Classification Systems

We'll start with several typical classification systems, such as Apgar, burns, and ulcers. These are classifications that you'll probably hear a lot while transcribing, therefore we should spend some time memorizing them.

Topics to be discussed include:

  • Apgar
  • Burns
  • Ulcers

Chapter 3: Bones

Many of the papers we've gone over in this course are required for transcription for an orthopedist. General chart notes, H&Ps, consultations, discharge summaries, and surgery reports can all be dictated by orthopedists. But, above all, you must understand bones.

Topics to be discussed include:

  • Arthritis
  • The Spine
  • Orthopedic Classifications

Chapter 4: Practice Corner

Let's take a closer look at each of these reports because they might be rather lengthy. Typically, the discharge report would include a lot of information about IV fluids. Because you won't hear this word in most other reports, I'd want to explain it to you.

Topics to be discussed include:

  • Discharge Summary Report
  • Intravenous Fluids
  • Death Summary Report

Chapter 5: Summary

We basically spoke about classification systems, bones, and discharge and death reports in this course. You learnt about Apgar, burns, and ulcers, which are three of the most frequent classification systems. The discussion then moved on to bones and the many transcribing challenges that they provide. You'll hear a lot about arthritis, vertebrae, and numerous orthopedic classifications throughout your transcription work.

Lesson 11: Infections, Blood, and Cells

Chapter 1: Introduction

We'll return to clinical issues once we've finished with these random topics. Infections will be discussed in Chapter 3. Then we'll look at cells and blood, which are tiny elements of the body. Then you'll see how everything you've learned can be put together in an autopsy report in our Practice Corner. This is most likely the longest and most thorough study you'll ever read.

Chapter 2: Miscellaneous Transcription Issues

Medical transcription encompasses a large amount of data that doesn't necessarily lend itself to classification. As a result, this will be a useful lesson to repeat from time to time to help you remember some of the finer points.

Topics to be discussed include:

  • Status Post
  • Nonspecific Dates
  • Another Capitalization Point
  • "Dictated but Not read" or "Transcribed but Not read"
  • Made-up Words

Chapter 3: Infections, Blood, and Tissues

Let's continue our clinical conversation by talking about infections and their transmission channels. You've already learned how to write the names of the viruses and bacteria that cause diseases, but there are some interesting aspects about how infections spread and take hold that you should know about.

Topics to be discussed include:

  • Infection Routes of Transmission
  • Blood
  • Tissues

Chapter 4: Practice Corner

We'll be looking at the autopsy report in this Practice Corner. The autopsy report is normally in three sections and is quite long and detailed.

Chapter 5: Summary

Didn't we cover a lot of ground today? In this session, you learned that medical transcription requires a great deal of attention to detail. Some things don't fit neatly into any of the categories, and those are the ones we talked about.

Lesson 12: The Nuts and Bolts of Working as an MT

Chapter 1: Introduction

It's an exciting time to enter the transcription field, but it's also a little frightening. We're about to undergo a massive transformation in terms of our organization, how we work, and how we'll be able to apply our expertise. The introduction of the electronic medical record (EMR) is the catalyst for this shift.

Chapter 2: Priorities and Workloads

Let's start by talking about how you'll be working. You must not only properly transcribe reports, but you must also prioritize the order in which you transcribe them.

Topics to be discussed include:

  • Turnaround Times
  • Speech Recognition and the EHR

Chapter 3: Employment and Certification Possibilities

MTs develop a wide range of talents, as you've seen throughout the course. Simply having medical terminology in your MT toolkit will make you a valued commodity. As a result, you can work in a variety of healthcare settings. Take a look at a few of the choices to get a sense of what's available to you.

Topics to be discussed include:

  • Independent Contractor
  • Private Practice
  • Additional Responsibilities in Private Practice
  • Large Contractor
  • Additional Duties of the Owner of an MT Organization
  • Consultant
  • Additional Training and Certification

Chapter 4: Practice Corner: The Health Story Project

The Health Story Project began as a project dubbed CDA4CDT (Clinical Document Architecture for Clinical Data Types), which stands for Clinical Document Architecture for Clinical Data Types. Its goal was to develop clinical document standards that would interact with electronic health records. It was essentially to ensure that all EHR firms could use the same set of regulations for document creation and storage.

Chapter 5: Summary

There are even topics to learn about which we are unaware of. That is what makes this field so intriguing right now. This is a career for you if you're the type of person that enjoys continuing to learn and progress. And if you have the ability to look into the future in addition to being a language specialist and a mind reader, there is a position for you in guiding this field into that future.

Recognition & Accreditation

All students who complete the course receive a certificate of completion with a passing score (for the online assessment) and will be issued a certificate via email.

There are 12 units of study

Introduction to Medical Transcription

This first lesson looks at the history of medical transcription as a career. You will find out how the field has evolved into its modern form, and you will explore the various skills and aptitudes that you will need to succeed as a professional medical transcriptionist. You will examine the type of work MTs produce, where you might work, and what might be in store for those working in this career field.     

Tools of the Trade

This lesson focuses on the tools of the trade. You will review a few of the reference books and discuss the types of Web sites that MTs use for research. Then you will learn about the hardware and software that today's MTs use on the job. By the end of this lesson, you will be sitting at your computer, listening to a real medical dictation audio file and looking at the Express Scribe software on your screen. As you listen to the medical report, you will practice starting, pausing, and rewinding the audio as you tap away on the keyboard.      

Understanding Medical Records

There are nine report types that medical professionals use most often in both hospitals and clinics. Medical letters aren't much different from traditional letters, but since you might not have typed a traditional letter in a while, you might need a refresher. You will finish the lesson with some specific tips about pathology reports and how to handle numbers and measurements. Then you will practice transcribing a medical letter and a pathology report.         

Listening Carefully

This lesson goes over how to listen most effectively, discussing the difference between hearing and active listening. You will also touch on many of the issues that keep voice recognition systems from replacing humans, including homonyms, synonyms, and antonyms. You will learn how to use phonetics and vowel sounds (as well as a few other tricks!) to help you figure out a word or phrase in a muddled recording. Next, you will learn about radiology reports and finish up by practicing transcribing one.       

Grammar, Sentence Structure, and Punctuation

This lesson covers some subjects that might make you cringe a little: grammar, sentence structure, and punctuation. But this will be a painless, maybe even enjoyable, journey through some of the basic principles of writing that will help you become a better MT. Then, in your Practice Corner, you will learn about SOAP notes and then turn your attention to infectious diseases and medications. You will also have the chance to transcribe a SOAP note and a radiology report in the assignment that accompanies the lesson.

Style

This lesson explores writing and talks about style from the MT's perspective. When you're transcribing, you must follow editorial directions in spelling, capitalization, and typographical display. And it's those directions that are the style MTs need to be concerned about. You may be surprised at how many different ways you can treat a single word. Should it be capitalized or lowercased? Should you abbreviate it, or should you spell it out? Should your numbers be in digit form or word form? Finally, in your Practice Corner, you will focus on the H&P report and practice transcribing one.    

Medical Terminology and Spelling

No matter what you transcribe, one thing is a given: Medical terminology will be a huge part of it. One thing to remember is that dictators aren't perfect. They might say one word when they actually mean another. Or they might say a word that has a sound-alike word, like cystitome and cystotome. If you have a good understanding of medical terminology, you can pinpoint the correct word to make sure your transcription is accurate. Then, in your Practice Corner, you will review the basic nature of heart disease and its treatment.         

Report Formatting and Word Processing

A critical component of the MT's work is the way you put your reports together. This lesson focuses on breaking your reports into sections with headings, subheadings, special line spacing, page breaks, and other formatting niceties. You will also take a closer look at ways to make your work easier with word processing shortcuts, AutoText, macros, and templates. Mastering them will make you a faster and more efficient MT! Today’s Practice Corner focuses on surgical reports. Surgical terminology is important to know, and it's also fascinating to take an inside look at what goes on in the operating room.

Checking Your Work

Another essential step in transcription is editing and proofreading your work. This lesson starts off with editing do's and don'ts, as well as what to look for when you're proofreading. In your Practice Corner, you will be covering a disease process that has, in some way, touched virtually everyone: cancer. Once you have an overview of cancer, you will work on the consultation report. Physicians often ask specialists to further evaluate their patients, especially cancer patients. So, this is a common report that you're likely to transcribe regularly. The assignment for this lesson includes a consult report to transcribe, and you will also get to practice proofreading.     

Classification Systems, and Discharge and Death Summaries

This will be a completely clinical lesson. You will learn about classification systems and their transcription foibles. And now that you have the bones of grammar and style down, you will learn about real bones. Finally, in your Practice Corner, you will learn about discharge and death summaries. They are very similar reports, but this lesson explains the subtle differences.        

Infections, Blood, and Cells

This lesson will be similar to the last in that it covers lots of clinical issues. It won't all be clinical, however. In your Practice Corner, you will see how everything you've learned can come together in an autopsy report. This is probably the longest, most comprehensive report you will ever come across. And, of course, you will have the chance to transcribe an autopsy report in the assignment!

The Nuts and Bolts of Working as an MT

By now you have the tools and the knowledge you need to dip your toe into the waters of medical transcription. But we still have a couple of big questions to answer. How do you manage your workload? Also, how do you establish yourself as a medical transcriptionist? And do you need more training?

Entry requirements

Students must have basic literacy and numeracy skills.

Minimum education

Open entry. Previous schooling and academic achievements are not required for entry into this course.

Computer requirements

Students will need access to a computer and the internet.

Minimum specifications for the computer are:

Windows:

  • Microsoft Windows XP, or later
  • Modern and up to date Browser (Internet Explorer 8 or later, Firefox, Chrome)

All systems

  • Internet bandwidth of 1Mb or faster
  • Flash player or a browser with HTML5 video capabilities(Currently Internet Explorer 9, Firefox, Chrome)

Students will also need access the following applications:

Adobe Acrobat Reader

Note: This course is not suitable for Macintosh users.

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Course Summary

Course ID: 007T9212
Delivery Mode: Online
Access: 3 months
Tutor Support: Yes
Time: 40 Hours
Duration: 24 Hours
Assessments: Yes
Qualification: Certificate of Completion

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