• Medical transcriptionists transcribe reports on a computer.typing #3 image by Adam Borkowski from Fotolia.com
  
  Medical transcription involves transcribing audio recordings into typed reports. Transcriptionists usually transcribe medical reports, correspondence letters and other administrative materials. They listen to the recordings on a headset and transcribe them using a foot pedal. The foot pedal helps them to pause the recording when necessary. The types of documents medical transcriptionists transcribe include operative reports, progress notes, consultations and discharge summaries. After transcribing, they return these documents to the physicians or other health care professionals who dictated them.
  
  

Consultation Reports

• A physician (that an admitting physician refers to) dictates these types of reports. This physician is usually a specialist in a certain area. The original physician requires him to consult on the patient. During consultations, doctors give second opinions of a patient's status or condition. The admitting physician then dictates a consultation report for the medical transcriptionist to transcribe. A consultation report typically involves a brief history of the patient's illness and a physical exam. It may also include x-ray and other test results and concludes with the consulting physician's observations and recommendations.
  
  

Operative Report (OP)

• The physician dictates the operative report, and medical transcriptionists transcribe this information after a surgery. It contains detailed information about the operative procedure. The parts of an operative report include preoperative and postoperative diagnoses, types of surgery performed, name of surgeon and staff, and description of the operative procedure. Depending on the procedure, there is also a count of instruments, sponges and blood loss. The operative report usually ends with the patient's condition and where she was transferred after the operation.
  
  

Discharge Summaries

• The admitting physician also dictates a discharge summary of the patient. It includes a summary of everything that occurred during a visit. In a discharge summary, medical transcriptionists transcribe details about laboratory data, x-rays and physical findings. There is also a discharge diagnosis and patient plan. If a patient transfers to another institution (i.e. nursing home) then the name of the report changes from discharge summary to transfer summary. If a patient died during a hospital stay, it will be called a death summary.