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Medical transcription, also known as MT, is an allied health profession dealing with the process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners. Medical reports can be voice files, notes taken during a lecture, or other spoken material.
A medical scribe's primary duties are to follow a physician through their work day and chart patient encounters in real-time using a medical office's electronic health record (EHR) and existing templates. Responsibilities will vary with the scribe’s department rules. Medical scribes generate referral letters for physicians, book appointments ...
Review of systems. A review of systems ( ROS ), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
Abbreviations are used very frequently in medicine. They boost efficiency as long as they are used intelligently. The advantages of brevity should be weighed against the possibilities of obfuscation (making the communication harder for others to understand) and ambiguity (having more than one possible interpretation).
Transcription was originally a process carried out manually, i.e. with pencil and paper, using an analogue sound recording stored on, e.g., a Compact Cassette. Nowadays, most transcription is done on computers. Recordings are usually digital audio files or video files, and transcriptions are electronic documents.
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