Medical Transcription Introduction
Medical Transcription is the process of converting voice dictation (typically either
cassette or digital format) into a permanent written record utilizing word processing
equipment and software.
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. Physicians and medical record handlers
alike must be extremely careful to ensure that detailed patient identification information
accompanies each procedure and examination report to avert potentially disastrous mix-ups.
Over time, all of this information accumulates in a centralized medical records repository
where it serves as a critical resource for patient care - facilitating accurate diagnoses
and appropriate treatments. Indeed, timely patient care often hinges on the ability of
Radiology, Pathology, and other specialty departments to quickly conduct their
examinations and report their findings.
Evolution and History of Medical Transcription
In the past, patient medical charts consisted of a series of abbreviated handwritten
notes that were funneled into the patient's file for interpretation by the primary
physician responsible for diagnosing ailments and prescribing treatment. Ultimately, this
hodge-podge of handwritten notes and typed reports was 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 things have changed considerably. Walls of filing cabinets have given
way to desktop computers connected to powerful mainframe systems where patient records are
prepared and archived digitally. This digital format allows for immediate remote retrieval
by any physician who is authorized to review the patient information. Reports are stored
electronically and printed selectively as the need arises.
While the transition from a paper based to an electronic format will take years to
complete, considerable progress has been made. Handwritten reports are largely a thing
of the past. Verbal dictation is now by far the most common method for documenting and
reporting the results of examinations and procedures. Physicians generally use either a
cassette based voice dictation system or a digital voice dictation system to record their
findings. Dictating reports verbally not only allows physicians to be more thorough in
their reporting, it also saves them a great deal of time.