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History[ edit ] Medical records have been kept since humans began writing, as attested by ancient cave writings. Medical transcription as it is currently known has existed since the beginning of the 20th century, when standardization of medical data became critical to research. With the creation of audio recording devices, it became possible for physicians and their transcriptions to work asynchronously, thus beginning the profession of healthcare documentation as we currently know it.
Today, speech recognition SRalso known as continuous speech recognition CSRis increasingly being used, with medical transcriptions and or "editors" providing supplemental editorial services, although there are occasional instances where SR fully replaces the MT.
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Natural-language processing takes "automatic" transcription a step further, providing an medical transcription editing services function that speech recognition alone does not provide although Ms do.
In the past, these medical reports consisted of very abbreviated handwritten notes that were added in the patient's file for interpretation by the primary physician medical transcription editing services for the treatment.
Ultimately, this mess of handwritten notes and typed reports were consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department.
Whenever the need arose to review the records of a specific patient, the patient's file would be retrieved from the filing cabinet and delivered to the requesting physician.
To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy. In recent years, medical records have changed considerably. Although many physicians and hospitals still maintain paper records, there is a drive for electronic records.
This digital format allows for immediate remote access by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises. Many MTs now utilize personal computers with electronic references and use the Internet not only for web resources but also as a working platform.
Technology has gotten so sophisticated that MT services and MT departments work closely with programmers and information systems IS staff to stream in voice and accomplish seamless data transfers through network interfaces.
In fact, many healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants PDAs and are now utilizing software on them. Overview[ edit ] Medical transcription is part of the healthcare industry that renders and edits doctor dictated reports, procedures, and notes in an electronic format in order to create files representing the treatment history of patients.
Medical transcription can be performed by MTs who are employees in a hospital or who work at home as telecommuting employees for the hospital ; by MTs working as telecommuting employees or independent contractors for an outsourced service that performs the work offsite under contract to a hospitalclinic, physician group or other healthcare provider; or by MTs working directly for the providers of service doctors or their group practices either onsite or telecommuting as employees or contractors.
Hospital facilities often prefer electronic storage of medical records due to the sheer volume of hospital patients and the accompanying paperwork.
The electronic storage in their database gives immediate access to subsequent departments or providers regarding the patient's care to date, notation of previous or present medications, notification of allergiesand establishes a history on the patient to facilitate healthcare delivery regardless of geographical distance or location.
The term transcript or "report" as it is more commonly called, is used as the name of the document electronic or physical hard copy which results from the medical transcription process, normally in reference to the healthcare professional's specific encounter with a patient on a specific date of service.
This report is referred to by many as a "medical record". Each specific transcribed record or report, with its own specific date of service, is then merged and becomes part of the larger patient record commonly known as the patient's medical history.
This record is often called the patient's chart in a hospital setting. Medical transcription encompasses the MT, performing document typing and formatting functions according to an established criterion or format, transcribing the spoken word of the patient's care information into a written, easily readable form.
MT requires correct spelling of all terms and words, occasionally correcting medical terminology or dictation errors. MTs also edit the transcribed documents, print or return the completed documents in a timely fashion.
All transcription reports must comply with medico-legal concerns, policies and procedures, and laws under patient confidentiality. In transcribing directly for a doctor or a group of physiciansthere are specific formats and report types used, dependent on that doctor's speciality of practice, although history and physical exams or consults are mainly utilized.
In most of the off-hospital sites, independent medical practices perform consultations as a second opinion, pre-surgical exams, and as IMEs Independent Medical Examinations for liability insurance or disability claims. Some private practice family doctors choose not to utilize a medical transcriptionist, preferring to keep their patient's records in a handwritten format, although this is not true of all family practitioners.
Currently, a growing number of medical providers send their dictation by digital voice files, utilizing a method of transcription called speech or voice recognition.
Speech recognition is still a nascent technology that loses much in translation. Dictation is read into the database and the program continuously "learns" the spoken words and phrases.
An MT can "flag" such a report as unintelligible, but the recognition software will transcribe the unintelligible word s from the existing database of "learned" language.Add-on Transcription Services: TrackDoc Solution This is a web-based solution that enables you to listen to the dictation, view transcribed documents, edit, and e-sign.
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Learn to be a Healthcare Documentation Specialist (HDS) formerly called Medical Transcriptionist. Both medical transcription & speech rec editing included. Medical Coding, Transcription & Scribes.
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