MEDICAL TRANSCRIPTION IN CALICUT

 Medical transcription, some of you may have heared about this and some of them not. This blog is for those who want want learn about medical transcription before deciding to choose a career on this. Before talking about the other thing in detail, first of all let me give a brief definition on medical transcription.       Medical transcription is the manual processing of voice reports dictated by physicians and other healthcare professionals into text format. Healthcare providers voice - record their notes and transcriptionists convert the voice files to text, normaly in digital format.

Types of medical transcription reports

-History and Physical report: This report is usually dictated by physicians when a patiant get admitted to the hospital. It starts with the main complaint, followed by hystory of the patient's current illness. Medical history, social hystory and family medical history.

-Consultation report: This is dictated by the physician to whom the admitting physician has reffered the patient. The consulting physician is normally a specialist in the area other than the admitting physician. It also includes a brief description about the illness of the patient and a specific physical exam based on the type of consultation requested. It may also include x ray or labaratory findings. This concludes with the physician's impression and treatment plan.

-Operative report: This report is dictated by the operating physician, that includes a detailed description about operative procedure. Details include pre-operative and post operative notes, the type of surgery, name of surgeon and a detailed discription of the procedure itself. The report will end with the disposition of where the patient was transfered when they left the operating room and the overall health condition of the patient.

-Radiology report: This report is dictated by the radiologist once the diagnosis and radiology procedures are completed. It includes the radiologist’s findings and interpretations of x-rays, CT scans, MRI scans, nuclear medicine procedures and so on.

-pathology report: This report is dictated by the pathologist and includes the microscopic findings of the sample.

-Laboratory report: This report includes the findings of examinations of bodily fluids such as blood levels and urinalysis. This report is rarely dictated separately but often included in the H&P, consultation or discharge summary.

-Hospital report: This will include all the reports that were dictated in the hospital – radiology reports, pathology reports and laboratory reports.

-Discharge summary: This report is dictated by the physician at the end of the patient’s stay at the hospital. All crucial reports right from the admission of the patient until discharge will be included. The report ends with a detailed plan for the patient. If this report is transferred to another institution, then it changes from discharge summary to transfer summary. If the patient dies, then it will be called death summary.

-Office report: Reports that are created in a medical practitioner’s office not treated as hospital reports. Some of these are initial evaluations, letters to referring physicians, patient introduction letters to specialists, and chart notes for each visit.

          The above mention are the main types of medical transcription. An accurate medical transcripts contain important medical data of future reference.