The Medical Reports
There are a variety of medical reports generated every day in physician offices, clinics, and hospitals. Medical transcriptionists should be familiar with those dictated in each work setting. Physicians in private practice frequently dictate office chart notes, letters, initial office evaluations, and history and physical examinations. Medical reports dictated in hospitals and medical centers are numerous in category; however, they invariably include dictations from the “basic four" reports: History and Physical Examination, Consultation Report, Operative Report, and Discharge Summary. Emergency Department Reports, hospital progress notes, and diagnostic studies are often dictated as well.
The Healthcare Record
The healthcare record is chronological, documented evidence of a patient's initial database, initial evaluation, identified problems and needs, objectives of care, prescribed treatment, and end results. The record may be paper, stored digitally in electronic format in a computer, or a combination of the two. The healthcare record is the property of the hospital, medical facility, or office in which it was originated, and it cannot be removed from the premises without a subpoena or court order. It is maintained in a Health Information Department usually headed by an RRA (registered record administrator), an ART (accredited record technician), or an MBA (master of business administration).
Technology & MT Equipment/ Tools
A discussion of medical transcription equipment should begin with the most important but often overlooked asset. . . the human brain. The machines used in medical transcription today are simple devices, and without human knowledge and intervention, machines are basically useless. The transcriptionist is the brain of the machine. Dictation systems: As physicians depend on their stethoscopes, scalpels, and tongue depressors, medical transcriptionists also depend on the tools of their trade . . . the computer, desktop controls, a foot pedal, and a headset.
Dictation systems have evolved through several different stages: wax cylinders, phonograph-type records, belts, tank systems, Mylar reel-to-reel tapes, and cassette tapes. All of these systems had drawbacks even though each represented an improvement over the current technology.
Today we still see some Mylar tape cassette dictation systems in use, but most have been replaced with digital technology. A digital system works much the same as a compact disc (CD). The CD reproduces sound using digital technology that is extremely complicated; however, the end result is a dictation that is without any background noise, hiss, or other extraneous sounds found on Mylar tape. In digital systems, voice files are stored in “digital" (computer) format rather than “analog" (tape) format, and the dictation is usually free from mechanical noise.
Keyboards have had a similar evolution cycle: from manual typewriter, to electric typewriter, to the Correcting Selectric® typewriter, to word processors, and currently to virtual keyboards and even speech recognition. The input of data, whether via traditional keyboard, Dvorak keyboard, steno machine keyboard, or speech recognition systems, proves once again that it's the human brain interacting with the machine, not the machine itself, that produces quality transcription.
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