Medical transcription is the process of converting / typing health care
professionals dictated notes into written transcripts. Medical
transcription is the act of translating from oral to printed
form (on paper or computer) the record of patient's medical
history and treatment. It is mandatory and legally binding on
the health care professionals to hardcopy any type of medical
treatment, procedure, diagnostic test, etc. and it must be documented
into a patient's permanent medical record. The patient information
is dictated by health professional into a digital or analog
recorder and/or through the use of a phone dictation system.
to transcribe - literally means
"to change into writing."
medical records - mean the records describing an encounter between a health care provider and a patient.
Medical Transcriptionist (MT) - (also called Medical Language Specialist) is a person responsible for
transcribing oral and/or written medical dictation and producing a permanent and uniform medical records.
turnaround time(TAT) - means the time it takes for the report to be dictated, transcribed and signed or verified by the physician.
use a computer and their favorite word processor to transcribe
this information into a typed document. These typed documents
either in hardcopy or softcopy are then forwarded to the dictator
for verification and approval. After approval these signed documents
become part of a patient's permanent medical record. These documents
can be Initial Evaluation / Consultation, Progress Note, Follow-up
Visit, Reassessment Sheet, Psychological Test, 6-month Psychological
Evaluation, Letter, Lab/Test Results, SOAP Note, Nutritional
Assessment, Preoperative Assessment, Postoperative Assessment,
Workmen's Comp, Telephone Conversation, Treatment Plan Summary,
Completion Note, History & Physical examination, Discharge
A written note in a patient's chart, a letter of thanks to a referring physician or law office, or a phone conversation to a pharmacist concerning a patient's medication can all be documented, and therefore become part of the patient's official medical record. Further, medical transcription, as part of the medical record, can be used by insurance companies, legal and government entities, and others to compile information about a patient or an individual; thus all documentation related to a patient having sought health care services should be kept undisclosed and private, or confidential, at all times. Medical transcription, once complete, should always be orderly, tidy and professional in appearance.