There are 2 types of editing in medical transcription: verbatim and light.
As a medical transcriptionist, you need to be able to make good decisions when transcribing. You may be asking yourself what happens when a dictator makes an obvious grammatical mistake in his/her dictation. What do you do if a dictator makes an obvious mistake in subject/verb tense or even starts out talking about a male patient but later in the dictation says the word “female?” What do you do if a dictator is talking about a left leg injury but later says “right” leg? These are all good questions and the answer will be contingent upon whether you are working on a strictly verbatim account or one where you may light edit.
A verbatim account will require you to transcribe exactly what the doctor says regardless if it’s incorrect. An MT may not edit at all on a verbatim account. On the other hand, if you are working on an account and are allowed to edit lightly then you could fix the errors that were described in the above paragraph. The cardinal rule of light editing is to never change the meaning of the sentence. Below you will find an interesting article written by an experienced MT about verbatim vs light editing. Enjoy!
Verbatim = Using exactly the same words; word for word. No matter how stupid it sounds, no matter if they are an ESL (English as a second language) doctor with their sentences backward, no matter if the sentence is three paragraphs long; you type it exactly the way it is dictated. Granted there are a few, and I do mean few, doctors that have an excellent command of English usage and know exactly where and what punctuation they want, but generally most dictators tend to string random thoughts and partial sentences into one long run-on sentence.
You might ask yourself, why would anyone want their transcription to look that way? I’ve asked myself that same question many times. You will encounter verbatim typing almost anywhere, including services, clinics, and hospitals. The question of “why” is somewhat of a mystery. Is it easier for the transcriptionist? The answer would be most assuredly it is. Who then has to take the ultimate responsibility for the sometimes incomprehensible dictation? The doctor signing their name at the bottom does. I’ve found over the years that this style of transcription leads to numerous edits. Once the doctors read over their dictation, that is IF they read over their dictation, they will inevitably want to change it, which, of course, leads to the transcriptionist having to spend twice as much time fixing it. This ultimately leads to longer turnaround times and frustration for the transcriptionist.
Thankfully, most of the places I have worked allow the transcriptionist to “light edit” or edit “on the fly,” versus full-blown editing of the entire document using an English usage checker, etc. Light editing is checking sentence structure and the proper use of tenses. Some of the other things you will be checking for include positions. For example, if the doctor is talking about a patient’s right arm and then starts saying left arm, the transcriptionist should be able to figure out which arm the doctor really means by what the rest of the dictation says. The same holds true for body parts, and this is where all that studying medical terminology comes into play. For example, if the patient is in for a foot problem and the doctor is talking about the patient’s metacarpals, you should know that the doctor means metatarsals. Another common error by dictators is the he/she error. They start off talking about “he” and wind up talking about “she.” Your job as a transcriptionist also includes catching these types of errors and correcting them.
You will find that after doing transcription for a while you will start to make these types of changes automatically or “on the fly” without having to read through your dictation to find the errors. I’m not saying you should not read through the document you just transcribed, but you will find yourself spotting and correcting these types of errors as they happen and proofing will become that much easier.
Courtesy of Glenn LePine, Medical Transcription Supervisor, St. Croix Regional Medical Center, St. Croix Falls, Wisconsin: I have worked in the medical transcription field for over 20 years. I have worked at one of the largest radiology centers in California, a large teaching hospital in Minnesota, many small clinics and services in California, Minnesota, and Wisconsin. I had my own transcription services for two years before taking a position as the supervisor at my current location. I have been the supervisor here for three years. We have a crew of 15 transcriptionists, 8 of whom work at home. We are a clinic and a hospital and we do all specialties. We currently utilize an electronic medical record system for the hospital dictations and a shared network drive for the clinic dictation.
A Few Examples
In conclusion of this section we will leave you with a few examples of light editing in medical transcription as follows:
As dictated: The patient come in today for a physical exam.
Light editing: The patient came in today for a physical exam.
As dictated: Mrs. Jones came in today for a routine physical exam and upon palpation of the left breast a soft mass was found so she will be sent for a mammogram and she will follow up with me in 2 weeks.
Light editing: Mrs. Jones came in today for a routine physical exam and upon palpation of the left breast a soft mass was found. She will be sent for a mammogram and will follow up with me in 2 weeks.
As dictated: During the exam the patient mentioned that he had been having headaches while reading, so patient was advised to try aspirin 325 mg b.i.d. to see if that would alleviate the headaches. He is to follow up in 2 weeks’ time.
Light editing: During the exam the patient mentioned that he had been having headaches while reading. Patient was advised to try aspirin 325 mg b.i.d. to see if that would alleviate the headaches. He is to follow up in 2 weeks’ time.