What is medical transcription?
By it’s simplest definition, Medical Transcription is the process whereby voice dictation is converted to a typewritten (hard copy or electronic) format. Of course, to truly understand the nature of Medical Transcription, a more detailed explanation is in order. Consider that each day in hospitals all over the country, thousands of patients are admitted and discharged. Examinations are conducted, procedures are performed and recommendations are made. It is not uncommon for multiple physicians to be involved in a simple procedure for a single patient. Radiologists, Pathologists, Anesthesiologists, Surgeons, and a host of other medical specialists must all coordinate their efforts to ensure that patient care is both adequate and appropriate. Underpinning all of these activities is a complex web of medical and patient information. Each patient-related activity and procedure must be meticulously documented and then added to the patient’s permanent record. Over time, all of this information
Whenever a patient goes to see any kind of medical professional, that doctor needs to dictate exactly what happened during their visit. Items they usually dictate on include the history of the present illness (HPI), past medical history, medications, allergies, and social history. He or she will also dictate what was found on their physical examination, any procedures performed, and the plan for treatment. The medical transcriptionist (MT) is the person who types up this dictation, putting each patient’s dictation into report form so that it may be filed in the patient’s medical charts. This information can then be used as a reference the next time the patient comes in for evaluation, and it may also be used if legal issues arise.
