The Health Insurance Portability and Accountability Act HIPAA prescribes a set of rules for health care specialists and institutions to follow in recording the services and products that they have given to their patients, and to ensure that, in the process of medical billing, accuracy of information is delivered and the privacy of the patient is guarded. In 2005, all health care specialists and institutions were required to follow the guidelines as set by the HIPAA in submitting their claims in order that such claims should be entertained.

It was to comply with these standards that the profession of medical transcription was born. Whenever a health care specialist consults with patients, the results of the process are marked down in the patient’s records. Within the guidelines issued by the HIPAA, this procedure has been modified. Today doctors attending to insured patients are obliged to dictate on a recorder the details of the consultation for a medical transcriptionist to encode.

For medical transcription, the information contained starts with the date of the consultation or procedure, the name of the patient, the patient number, the name of the doctor, and any referring doctor, as well. This is followed by a brief statement of any background of the patient or other circumstances that the doctor finds relevant to the process on hand. The doctor then records his initial diagnosis of the patient’s ailment. He then mentions any laboratory tests done to the patient, as well as the results of each test. Finally, the doctor mentions his final diagnosis, as well as any medical prescriptions and recommendations that were given to the patient.

The task of the medical transcriptionist is to transpose the voice recording into a transcript that has a standard format. It is this transcript that will form the basis of any claims to be submitted to insurance companies. The job of the medical transcriptionist is doubly more difficult than that of the medical encoder. Besides having to have a very sensitive ear, he or she needs to be well versed in the general terminology of medical science, as well as the specific terminology used in the specific branch of medicine he or she is transcribing for.

Not all voice recordings done by doctors are clearly recorded. There are recordings that are faint or marred by background noises or the doctor’s tendency to eat up some of the common medical terms. Some doctors also tend to slur over phrases that are common usage in the type of consultation or procedure being recorded.

The medical transcriptionist has to cope with and surpass all the shortcomings of the recording in order to produce a perfect transcription of the voice recording, containing all the details mentioned by the doctor, although, in cases were it is needed, clarification can usually be obtained from the doctor.

Medicine is a growing field and job openings for medical transcriptionists are numerous, making this a potentially lucrative career choice.