Medical transcription is a process that begins when a patient goes to see their doctor, and it’s a process that’s very important to the medical community. Medical transcription allows patient medical records and history to be stored physically or electronically in one central location. This allows doctors to quickly review the patient’s medical background and have a clear understanding of their physical condition when the patient comes to see them. Medical transcription ensures that doctors will be better able to understand their patient’s medical history so that patients can then receive the best care possible.
When an individual goes to see their doctor, they will discuss with their doctor any problems they are having or any concerns they may have. If the patient has a sickness or a certain condition, the doctor may order laboratory tests, prescribe medications, and give advice to the patient about how to treat the condition. If the patient is receiving a physical examination or general consultation, the doctor will make general notes and suggestions about the patient’s overall health. Once the consultation is over and the patient has left the office, the doctor will use a voice recorder to fully detail the patient’s visit, all tests that were ordered, medication prescribed, and general advice that was given.
The type of recorder the doctor uses will vary. Some choose to use simple handheld devices while some medical facilities have recorders that look similar to regular telephones. By speaking into these phones, the doctor’s recording is then saved onto a huge server within the medical facility and saved there for the medical transcriptionist (MT) to transcribe. Once the MT receives the recording, either as a tape cassette or as a digital recording, they will type it into a document, which will then be considered a medical record, which are legal documents. Upon subsequent visits to the doctor, the patient’s entire medical file and history will be contained within their chart. This allows the doctor to quickly review past visits and make quick evaluations.
The entire process of medical transcription is crucial to proper patient care. If an MT mishears something said in the recording, or types in a wrong dosage or diagnosis, it could have disastrous results and in the end, patients could suffer greatly. Also, if a doctor does not speak clearly enough for the MT to properly interpret it, this could also lead to much confusion and inaccurate transcriptions. Both the MT and the doctor play critical roles to ensure that all of the medical information that lies within a patient’s medical chart is accurate and up to date. Doctors must have the patience and the time to speak slowly and clearly, which is often difficult in medical atmospheres such as emergency rooms. The MT must also have a clear understanding of medical terminology, descriptions of procedures and diagnoses, outstanding listening skills, and good research skills.