Medical transcription

Medical transcription, also known as MT, is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians or other healthcare professionals, into text format.

Medical records have been kept since humans began writing, as attested by ancient cave writings. Medical transcription as it is currently known has existed since the beginning of the 20th century, when standardization of medical data became critical to research. At that time, medical stenographers replaced physicians as the recorders of medical information, taking doctors' dictation in shorthand. With the creation of audio recording devices, it became possible for physicians and their transcriptionists to work asynchronously, thus beginning the profession of healthcare documentation as we currently know it.

Over the years, transcription equipment has changed from manual typewriters to electric typewriters to word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings. Today, speech recognition (SR), also known as continuous speech recognition (CSR), is increasingly being used, with medical transcriptionists and or "editors" providing supplemental editorial services, although there are occasional instances where SR fully replaces the MT. Natural-language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide (although MTs do).

In the past, these medical reports consisted of very abbreviated handwritten notes that were added in the patient's file for interpretation by the primary physician responsible for the treatment. Ultimately, this mess of handwritten notes and typed reports were 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, medical records have changed considerably. Although many physicians and hospitals still maintain paper records, there is a drive for electronic records. Filing cabinets are giving way to desktop computers connected to powerful servers, where patient records are processed and archived digitally. This digital format allows for immediate remote access by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises. Many MTs now utilize personal computers with electronic references and use the Internet not only for web resources but also as a working platform. Technology has gotten so sophisticated that MT services and MT departments work closely with programmers and information systems (IS) staff to stream in voice and accomplish seamless data transfers through network interfaces. In fact, many healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants (PDAs) and are now utilizing software on them.

...
Wikipedia