Medical Transcription
Medical transcription has existed since the beginning of medical care and research. Ancient cave writings attest to the earliest forms of healthcare documentation. While the medium changed from metal plates to clay tablets, from hieroglyphs on temple walls, to papyrus, to parchment, to paper, and most recently to electronic files, the reasons for maintaining records have always been the same: to record an individual's health care and the achievements of medical science.
Until the twentieth century, physicians served both as providers of medical care and scribes for the medical community. After 1900, when standardization of medical data became critical to research, medical stenographers replaced physicians as scribes, taking their dictation in shorthand.
The advent of dictation equipment made it unnecessary for physician and scribe to work face-to-face, and the career of medical transcription was born. As physicians came to rely on the judgment and deductive reasoning of experienced medical transcriptionists to safeguard the accuracy and integrity of medical dictation, medical transcription evolved into a medical language specialty.
In the twenty-first century, many medical transcriptionists are using speech recognition technology to help them create even more documents in a shorter time. Medical transcription is one of the most sophisticated of the allied health professions, creating an important partnership between healthcare providers and those who document patient care.
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In the broadest sense, medical transcription is the act of translating from oral to written form (on paper or electronically) the record of a person's medical history, diagnosis, treatment, prognosis, and outcome.
The industry is moving toward electronic health records, allowing storage of an individual's health history so that it can be accessed by physicians and other healthcare providers anywhere.
Physicians and other healthcare providers employ state-of-the-art electronic technology to dictate and transmit highly technical and confidential information about their patients. These medical professionals rely on skilled medical transcriptionists to transform spoken words into comprehensive records that accurately communicate medical information. Speech recognition systems also may be used as an intermediary to translate the medical professional's dictation into rough draft. The medical transcriptionist further refines the draft into a finished document.
Keyboarding and transcription should not be confused. The primary skills necessary for performance of quality medical transcription are extensive medical knowledge and understanding, sound judgment, deductive reasoning, and the ability to detect medical inconsistencies in dictation. For example, a diagnosis inconsistent with the patient's history and symptoms may be mistakenly dictated. The medical transcriptionist questions, seeks clarification, verifies the information, and enters the correct information into the report.
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