Medical Transcription

The medical transcription can be exactly defined as the process of making copies of dictated or written records, which are related to the practice of medicine.

In other way you can define medical transcription as an act of translating from an oral to written form, which can be on paper or electronically.

A medical transcriptionist (also called as an MT) is the person who accurately transcribes the medical records dictated by the doctors or others.

The type of reports in medical transcription:

1. Initial Consultation.

2. Progress notes.

3. Discharge summary.

4. Operative reports.

5. Radiology reports.

6. Letters.

7. Diagnostic procedures.

Introduction to Medical Transcription:

When someone falls sick, he/she visits a physician. The physician needs to keep a record of the patient’s treatment, which includes the illnesses, causes of illnesses, medications being taken, allergies, physical exam, radiological studies performed if any, treatment so far, future treatment, procedures performed if any.

Practically, it is very difficult to do all those things manually or to employ so much manpower. So, the physician dictates all the above-mentioned things in a sequential manner into a digital recorder called Dictaphone, which records the audio in the form of a voice file. Dictating is much easier and less time consuming than writing all the things down on the paper. This voice file is then sent to the medical transcriptionists working in-house or across the world through internet. They listen to the audio with a headphone and transcribe the report. The transcribed document should match exactly as dictated by a physician. Minimum accuracy should be 98.5%.

Use of Medical transcription:

But what is the need for all those documentation? Nearly all other countries in the world do not maintain such type of extensive records. Still, there is no problem.

In America, the cost of healthcare is very high. So, most of the people prefer to have medical insurance. Without the medical insurance, it is very difficult for a common people to have good quality medical treatment.

Approximately 80-85% population of America is covered by medical insurance. This insurance covers some specific drugs and procedures. Therefore, while processing the claims, insurance companies have to go through the medical records of the patient. The healthcare documentation plays a very important role here.