The responsibility of a medical transcriptionist

Medical Transcription ExchangeThe comments in the AHDI Lounge discussion on credentialing just gets more and more interesting (see my prior post Do as I say leadership).

The latest comment that drew my interest is Lea Sim’s response to one of my comments, where she says:

…unless we can make a solid argument to someone like CMS or HHS or the Joint Commission that there is at least SOME risk to the patient in having unqualified hands in a health record, considering how inconsistently physicians actually read the records they put their signatures to.

I have disagreed with this position in the past and I’m going to keep disagreeing with it.

I want to know if there are any other highly educated, highly trained professionals preparing medical-legal documents who wouldn’t be expected to ensure that those documents are accurate before they sign them. Oh heck – I don’t know of many professionals, highly trained or otherwise, who don’t understand it’s their responsibility to ensure the accuracy of the documents they sign.

I was a secretary for years and not only are non-medical professionals as a whole more conscientious and courteous about their dictation, they all also understood that they needed to actually read the transcribed document before they signed it. After all, that’s their name on it, not the transcriptionist’s. Whoever is going to receive the document doesn’t know – and frankly doesn’t care – who typed it. If there’s a problem with it, they call the person whose signature is at the bottom, they don’t start hunting down the person who typed it.

I’ve had insurance adjusters read a transcribed letter telling a claimant that their case has been settled more carefully than some doctors read an operative report before they sign it. That’s not a reflection of how much either professional trusts the person who transcribed their dictation, either.

Now, I understand that doctors are busy. But really – what special power relieves them of the responsibility of making sure that the medical records they create and have responsibility for and to which they affix their signature are an accurate representation?

Let me quote myself, from a prior post Whose medical records are they anyway?

Let me review, in case anyone missed my comments a couple years ago in Advance for HIM. The average medical transcriptionist has a high school education. The average physician has a high school education, plus 8 years of higher education. The average medical transcriptionist is trained on the job. The average physician spends three to six years in internship and residency training programs. The average medical transcriptionist makes less than $30,000/year. The average family physician makes over $130,000 a year, and that’s the lowest-paid group; specialists can make up to $800,000 a year. Physicians are one of the highest-paid occupations in the U.S. The physician is trained, licensed and paid to make medical decisions; the medical transcriptionist is not. The records belong to the physician, not to the medical transcriptionist. When the physician signs the document – with a pen or electronically – he or she is verifying that it is a medical-legal document that is true and accurate to the best of his/her knowledge.

Which one of these people do YOU think should be responsible for making sure the documentation is correct?

As long as AHDI keeps beating this drum, I’m going to keep repeating myself. This is a dangerous, slippery slope. Making transcriptionists responsible for the accuracy and completeness of the medical record does not make medical transcription more valuable in the healthcare community.

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13 thoughts on “The responsibility of a medical transcriptionist”

  1. “But if there are “more qualified CMTS who should be running the association,” it would help GREATLY if any of those people would actually step up to the plate and run for a board position. We would not be having this discussion if that were the case, and you are well aware that we had our hands full trying to fill the ballot for every open position. Something has got to give here. There needs to be some transitional “grace” extended over this board while we get more people to (a) get their CMT and/or (b) be willing to run for the board, because right now, we’re spending a lot of time here hounding the handful of people who are actually willing to serve at that level. :(”

    I find this utterly fascinating. Watching the dynamics of this group is better than soap operas, it just needs the dramatic music in the background to set things off on the right track.

    If I was in charge of a national group that was rapidly losing members, that seems to have been shunned by the majority of working MTs who are not members (and the numbers of nonmembers is far, far higher than the dwindling voting and nonvoting membership combined) I would hope common sense would make me understand that IF no one was signing on to take responsibility for running the group; if MTs have STOPPED joining the group at all; then something was/is wrong with the goals of the group and something is seriously wrong with the way the group refuses to acknowledge that or attempt to make any sort of change within itself that might change that situation. Its a “Her’es your sign” moment of pretty significant size and really hard to ignore I would think.

    Yet, here they sit, whining that no one will step up to to plate … but they are not doing a darn thing that might actually encourage those MTs to do some stepping. Instead the MTs are still getting pounded over the head with “we are the only ones who know what to do, so YOU must do all the changing, not us.” Obviously that is not working well at all.


    1. Sure, I have my CMT, for many years now. Do you have yours?

      If you are seriously interested in board positions AHDI just recently released the list of who is running for this year, I believe you can still add your name to that list as a write in candidate … it is easily found online. πŸ™‚


      1. My hat’s off to you for maintaining your CMT – truly.

        However, I wonder just how you justify all the anti-AHDI and negativity toward credentialing when you, yourself, carry and maintain at least some sort of relationship and support to that organization and credentialing theory.

        Speaking out of both sides of one’s mouth really is quite the talent! I keep looking for you and JulieW8 to appear with Jeff Dunham … LOL.

        Paul C.

    1. For all your soapbox sermons and Nae being part of your faithful backup choir, just wondered if you really live up to your own preaching.

      Talk about “do as I say” leadership! LOL

      Paul C.

        1. Sometimes ya just have to start churning ice cream.

          Today it is going to be peach πŸ™‚ It is astonishing how that changes one’s outlook on some things πŸ™‚


  2. As a medical transcriptionist, CMT or not, I don’t know how I can be held responsible for the accuracy and completeness of the medical report I just transcribed. How would I know if the doctor was giving me the past medical history that actually applied to this patient and didn’t mix it up with somebody else? Same for the medication list or any other part of the report.

    I also agree that AHDI is not seeing the huge sign and not getting the very loud message that MTs are sending.

    It will be interesting to see who Peter’s replacement will be and what direction the association will try next.

  3. I’m not sure it’s the sign that’s not seen. I think perhaps it’s just that MTs haven’t really come to grips with the changes in the organization that has made it no longer just about MTs anymore. Starting with the name change, that started it. Yet we still have an expectation that it’s all about MTs. It’s simply not. Even in the referenced discussion here, it’s so off track. The resolution of the HOD does not say anything about a CMT or RMT, it simply says credential.

    I think there is a constant struggle for relevance and that’s why you see the push above. I do hear from reports from the Florida meeting last week that an offer has been extended to a candidate for the CEO role. However, it’s the board that sets direction, not a CEO (at least that’s how it is supposed to work), so I can’t imagine one person changing that.

    The lack of people willing to step up to run for the board roles is telling, and frankly makes me sad. I was thinking today what a waste financially to even have an election when there are only two or three places where there’s any real “competition” for the role. Might be better in an already financially strapped organization to save the money and just give those folks the roles.

  4. What could be the cost of this election? Isn’t it just online voting only? Is AHDI actually going to mail something to members? If so, that would be a complete waste of money. I thought it was just online voting.

    I feel the CEO definitely has influence over the board, based on past observations.

    Is it an expectation that the association should be about MTs or is it a desire by the members? Or maybe there’s no difference between expectation and desire? Maybe too many of us long-time members are nostalgic for the way the association was in the past.

  5. Yes, elections are totally electronic now. There’s still a cost involved in that, both for the technology and the staff time to do it. Sure a CEO has influence, but frankly I think that’s part of the problem. We “give” that power to the CEO, which means it’s easy to blame them when the reality is that it’s the board who holds the power.

    I think you’re right that expectations and desire in this instance may be the same thing. I’m not sure the general membership really understood the changes that were made with the name change and the change in the mission, and now that they are starting to understand it, they’re casting their own votes on it, by choosing to not be there.

  6. Why should any American MT recognize AHDI as an authority or trade assocation for anyone but overseas workers? Does the American Bar Association credential Indians? Does the AMA stump to have Parkistan doctors get an American MD so they can practice medicine in America for pennies on the dollar?

    Why in the world do American MTs even acknowledge AHDI as leadership at all or ‘decision makers.’ Sure, most of the people in the group are fantastic, but the purpose of the group became very clear when “American” was taken out of their name.

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