Medical transcription is the practice of converting a practitioners voice recorded dictation into written documentation. Any treatment or procedure which the patient incurs must legally be documented in their health record. This includes any of the following:
- • Medical treatments
- • Procedures
- • Diagnostic tests
- • X-rays, CTscans, MRIs
- • Medical reports
- • Worker compensation reports
- • Operative reports
- • Consultations
- • Discharge summaries
The accuracy of health records is at the forefront of quality patient care. Accurate documentation ensures medical records meet the needs of all healthcare professionals, especially those who rely on the medical information in shared medical reports and other health records
Medical Transcription is an essential component in the correspondence between patients and health professionals. Information may be transcribed and forwarded to patients, medical doctors, specialists or allied health providers, such as physiotherapists.
Successful transcriptionists have good keyboarding skills, quick typing speed, and knowledge of transcription guidelines and procedures, a working knowledge of medical terminology, good communication skills, sound English, and proficiency in grammar and punctuation. Finally identifying the appropriate style and presentation for medical information is vital to the professional look of the finished document.