The Need for Clarity in Medical Histories

The Need for Clarity in Medical Histories

Chronicles of history are important in the study of the present. Historians refer to ancient literature and art to trace back the roots of modern phenomena and traditions. Comprehensive pieces of art and literature are essential in the study of history. Otherwise,they will be useless in explaining ancient practices and beliefs.

Same is true in preserving medical records. Medical records are technically called medical history. Medical histories contain documents on check-up, diagnosis, prescription, and treatment of patients. Collectively, these are archived in a hospital's library of medical history.

Doctors and medical professionals refer to these documents every patient's check-up session. A medical history is essential in the continuous treatment of a patient's ailment. Hence, medical histories must be clear and comprehensive to ensure the accuracy and precision of medical information.

A medical history is contained in a medical report. Medical reports are created by medical transcriptionists. These reports are taken from a doctor's diagnosis and treatment form which are sent to the transcription department after a patient's check-up. In the past, diagnosis and treatment forms are in a handwritten format. These are compiled in an envelope which serves as a patient's medical history. Included in this envelope are the expenditure records of medical billing companies.

The format of medical histories improves with the discovery of word processors. This advanced technology enables medical transcriptionists to convert diagnosis and treatment forms in a more comprehensive manner. The invention of Continuous Speech Recognition (CSR) and Speech Recognition (SR) system makes medical transcription easier. These systems automatically digitize voice-recorded reports of doctors in a word document. Medical transcriptionists simply review and check possible mistakes in the CSR's and SR's medical report. Some medical billing companies also use CSR and SR technology.

Nevertheless, CSR's and SR's still cannot be at par with the reports of medical transcriptionists. CSR's and SR's cannot recognize mumbled and mispronounced words; hence they cannot be and encoded in a medical report. It can lead to patient misdiagnosis and medical errors that could be dangerous to the patient's health. On the other hand, medical transcriptionists provide a comprehensive medical report with accurate information on a patient's medical condition. Because of this, most hospitals and medical billing companies still hire the services of medical transcriptionists.

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