What is medical transcription? Why do we need it?Posted on:8/27/2005
Written By: Shailesh
|Medical Transcription is usually carried out for medical professionals operating out of small clinics to large hospitals. These transcribed records are used for purposes of archives, reference or serve as legal proof of medical advice.|
Medical Transcription as the name suggests is the diligent process of converting a health care provider’s dictated notes in to accurate and readable data records.
This includes a sophisticated yet simple method of listening to voice data and converting it in a hardcopy and readable form. The process of converting this voice data in readable format can be basically described as transcription. Most of the material transcribed include patient’s history, physical reports, patient assessment, workup, therapeutic procedures, clinical course, diagnosis, prognosis, clinic notes, office notes, pathology reports, operative reports, consultation notes, discharge summaries, letters, psychiatric reviews, laboratory reports, x-ray reports and many others similar kinds of medical records, etc.
It is not as easy as a task of just transcribing voice data but also involves a lot of editing of dictated material for grammar, medical terminology and clarity as necessary and as appropriate. Medical transcription is usually carried out for medical professionals operating out of small clinics to large hospitals. These transcribed records are used for purposes of archives, reference or serve as legal proof of medical advice. In concise, this process starts with the health care providers seeing patients in their hospitals and clinics and dictating and recording important information about the patient’s history, physical examination, diseases, procedures, laboratory tests and diagnoses in the form of voice data. These are then heard by the medical transcriptionists who accurately interpret it and transform in to much needed readable and documented format.
Need for Medical Transcription
Well, as somebody has so rightly said ‘Necessity is the mother of invention’ and its apt usage can be applied for this process too. Over the years, there has been always a constant need and requirement to have a properly documented data of each and every individual’s health records over his lifetime. This necessarily requires an efficient work management system along with detailed and yet organized documented proof of each and every hospital visit during an individuals lifetime. Consequent to this, the Flexner report on medical education (1910) was the first formal statement made about the function and contents of the medical record, which encouraged physicians to keep a patient oriented medical record.
In the 1960’s, hospital information systems (HIS) emerged, which helped physicians keep accurate patient health data. Similarly, Problem oriented medical records (POMR), made in 1969 by Larry Weed focused on the organization of all diagnostic and therapeutic plans keeping in mind the medical problems. Thus, started the need for maintaining accurate and organized medical data and with that the need for medical transcriptionists paving the way for a new emerging business of medical transcription.
There are no doubts with regard to the benefits this process has brought to the whole medical fraternity and general public as a whole.