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. These are dictated over the phone or uploaded digitally via the Internet or through smart phone apps.
Medical transcription as it is currently known has existed since the beginning of the 20th century when standardization of medical records and data became critical to research.[1][2] At that time, medical stenographers recorded medical information, taking doctors' dictation in shorthand. With the creation of audio recording devices, it became possible for physicians and their transcribers to work asynchronously.[3]
Over the years, transcription equipment has changed from manual typewriters, to electric typewriters, to word processors, and finally, as of 2022[update], to computers. Storage methods have also changed: from plastic disks and magnetic belts to cassettes, endless loops,[clarification needed] and digital recordings. Today, speech recognition (SR), also known as continuous speech recognition (CSR), is increasingly used, with medical transcriptions and, in some cases, "editors" providing supplemental editorial services. Natural-language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide.
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, these handwritten notes and typed reports were consolidated into a single patient file and physically stored along with thousands of other patient records 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,[when?] medical records have changed considerably. Although many physicians and hospitals still maintain paper records, the majority are stored as electronic records.[4] 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 healthcare providers today[when?] work using handheld PCs or personal data assistants (PDAs) and are now utilizing software on them to record dictation.
Medical transcription is part of the healthcare industry that renders and edits doctor dictated reports, procedures, and notes in an electronic format in order to create files representing the treatment history of patients.[5] Health practitioners dictate what they have done after performing procedures on patients, and MTs transcribe the oral dictation, edit reports that have gone through speech recognition software, or both.[6]