Medical Transcription

Medical Transcription in Detail:

Medical transcription is the act of transcribing or typing a doctor’s report on his/her patients from dictated audio files into written text (usually electronically, i.e. on a computer). Whenever a medical professional – doctor, nurse or other healthcare personnel – sees a patient, he/she maintains a record of certain important aspects of the patient’s health.

This usually consists of:

1.       Current issue(s) the patient is presenting with;
2.       History of present illness;
3.       Medications he/she is on;
4.       Prior surgeries or problems (if any);
5.       Details of physical examination performed;
6.       Laboratory values for any test(s) performed; and
7.       Conclusion or diagnosis.

These medical records are usually of four types:

a.    Consultation (first visit)
b.    Follow-up/Clinical visits (second or subsequent visit)
c.    Operative procedures (surgeries)
d.    Letters to other doctors recommending a patient for consultation or          second opinion.

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