Healthcare documentation specialists, formerly known as medical transcriptionists, listen to voice recordings (dictation) and convert them into written reports. They may also review and edit medical documents created using speech recognition technology. Healthcare documentation specialists interpret medical terminology and abbreviations in preparing patients’ medical histories, discharge summaries, and other documents. Most healthcare documentation specialists work for hospitals, clinicians’ offices, and third-party transcription service companies that provide transcription services to healthcare establishments.
Characteristics that contribute to the success of a healthcare documentation specialist include:
The most recent report from the U.S. Bureau of Labor Statistics indicates 43,900 individuals are working as Healthcare Documentation Specialists in 2024, with projected employment of 41,700 in 2034. The median pay for a Healthcare Documentation Specialist is $37,550 per year or $18.05 per hour.
See the latest U.S. Bureau of Labor Statistics report for medical transcription
The course is designed to be completed in 12 months with approximately 15-20 hours of committed time each week. The amount of time to complete the course also depends on the amount of medical, English grammar, and typing experience a student may bring to the course. You will transcribe over 2100 minutes of dictation and over 800 reports in the AHDPG program. You will also have access to over 250 additional reports to enhance your learning experience if you wish to practice additional specialties.
Introduction to Healthcare Documentation
The Introduction semester is designed to help you understand the field of healthcare documentation and the core concepts of performing optimally as a medical transcriptionist/speech recognition editor. The course includes an overview of the medical transcription industry, the tools, materials, and types of documents created by Healthcare Documentation Specialists, and the basic grammar principles that provide a firm foundation for mastering the fundamentals needed to create accurate medical reports.
Medical Knowledge I
This semester covers the following specialties: Laboratory Studies, Medical Imaging, Dermatology, Ophthalmology, Otorhinolaryngology, Pulmonology, Cardiology, and Gastroenterology. During this phase of training, the basic concept of pathology and the processes pathologists use to diagnose a given condition will be presented. Dermatology topics will describe the anatomy, common conditions, diseases, and disorders that affect the skin and the treatment options for each. Otorhinolaryngology topics will describe the anatomic structures of the eye, ear, nose, and throat. In Pulmonology, the respiratory system structure will be identified along with the functions of each. Students will come away with an understanding of the common tests and diagnostic procedures involved, and the ability to correctly define, spell, and pronounce the medical terms associated with each specialty.
Medical Knowledge II
This semester covers the following specialties: Urology, Obstetrics, Gynecology, Orthopedics, Neurology, Immunology, Oncology, and Endocrinology. During this phase of training, the students will identify the basic anatomic structures that make up the female reproductive system, discuss the anatomy of the bone and the organization and structure of the skeleton, and understand the structures of the nervous system, including the brain, spinal cord, and nerves. As the student progresses through this semester, they will also become familiar with the function of the immune system, discuss the concept of cancer and cell structure, and identify and locate the organs and glands related to the endocrine system. Students will come away with an understanding of the common tests and diagnostic procedures involved, as well as an ability to correctly define, spell, and pronounce the medical terms associated with each specialty.
Advanced Transcription
The first part of this semester will cover the medico-legal aspects of the healthcare record, outlining the purpose of the healthcare record and the content and formats commonly seen in today’s healthcare documentation. This semester of the program will also establish a general knowledge of existing standards and regulations set by various organizations including AHDI, AHIMA, AMA, JCAHO, NCQA, HL7, ASTM, and CMS. In the second part of this semester, the student will accurately transcribe commonly dictated cardiology and surgical reports from various dictators using language skills and medical knowledge to appropriately edit, revise and clarify while transcribing dictation, without altering the meaning of the dictation or changing the author’s style.
The Practicum
During this phase of the training, under the supervision of the student’s instructor and Education Assistants, you will begin transcribing medical documents from “dead voice files” – inactive, past dictation by real clinicians. Students will work with one of the Education Assistants or their instructor throughout the Practicum and receive extensive feedback on report transcriptions. The Practicum includes authentic dictations, giving students experience with multiple specialties, accents, and styles representative of the work they will receive when employed.
Students completing this program can sit for the Registered Healthcare Documentation Specialist (RHDS) exam administered by the Association for Healthcare Documentation Integrity (AHDI).
The all-inclusive program fee covers everything a student needs to complete the Healthcare Documentation Specialist program, including:
Professional Transcriptionist Foot Pedal (IN-USB-2)
AHDPG has partnered with The Voice Processing Specialists (TVPS) to offer a professional grade foot pedal to suit our students when in need of a replacement. By clicking on the Purchase Foot Pedal button, you will be directed to the TVPS website to purchase your new pedal. The IN-USB-2 Infinity Professional grade foot pedal is the successor of the IN-USB-1 standard of the industry that all other pedals try to attain. Weighing in at 2.3 lbs. the new sleek design is the solution to a new generation of “hands-free” transcription. The IN-USB-2’s low profile offers a wider flare to accommodate all foot sizes for longer-lasting comfort. Durable, yet sensitive switches provide you with an easy touch and the Plug and Play features allows for a quick connection. The INFINITY IN-USB-2 is 100% compatible with the IN-USB-1. This pedal is compatible with Chartscript, DocQscribe, Express Scribe, and many other platforms.
Price $55.00 – price and shipping subject to change by the vendor.
Professional Transcriptionist Headset
Selection of quality headsets according to your needs and preferences. The initially supplied headset is the Spectra PC headset. Any headset that will work with your particular PC should be fine to use.
This program qualifies for the MyCAA Tuition Assistance Program sponsored by the Department of Defense—a program designed for military spouses.
Online Team Lead / Instructor
Breena’s career in medical transcription began while working for a medical center in New Hampshire. After 6 years there, she joined the facility’s transcription department, where she worked for 3 more years before making the move to work at home, first with a large national medical transcription company. Not finding that company to be the “perfect fit,” Breena found her new “home” in January 2004 and has been with her AHDPG family ever since.
Breena began working with AHDPG (initially TRS/TRS Institute) as an MT and has had the privilege of wearing many hats, including quality assurance and supervisory roles. She joined the education team in 2007. She enjoys working with students hoping to enter this exciting and ever-changing field.
Breena graduated from Oberlin College in Ohio, double majoring in French and Sociology. She moved to North Carolina in 2009 from New Hampshire and lives with her husband, two boys, and their expanding household of pets. She enjoys spending time with her family, reading, baking, music, traveling, volunteering at the Humane Society, and Geocaching.
(Medical Transcription Editing)
