Is documentation of Medical letters and records mandatory, if so how is it done today!

Sep 4
16:01

2012

Sharad Gaikwad

Sharad Gaikwad

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Storage of records and documentation is very common and vital in every industry. It is the same in medical industry also, wherein the doctors need to record all the Medical Letters, prescriptions, diagnostic details, scan reports and other procedures done in order to refer them in future if necessary.

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These records are also mandatory in the healthcare sector in order to avail any medical insurance by the patients. But,Is documentation of Medical letters and records mandatory, if so how is it done today! Articles the task of storing all the details by the doctors is not easy because of the busy schedule for the doctor. Nowadays, the medical transcription industry has paved way for storing these details in a word format.

All the Medical Letters, medical procedures conducted, diagnostic details, prescriptions and reports are sent by the doctors in the form of recorded voice using the digital recorders, and then converted to the text by the medical transcriptionists. Documentation of medical records is quite common and is already grown in the western countries. But, in the developing countries like India, Pakistan, etc. the transcription industry is a growing industry. Nowadays, medical transcription work is being outsourced by the western countries in order to make their work simpler and cost-effective. Similarly, this industry has given job openings and a good income source for the developing countries as well. It has even provided a source of income for the homemakers by enabling them work as freelancers.

Medical Typing cannot be neglected in the medical transcription industry. It is not like the typing work that is done in other fields. Medical Typing requires a basic knowledge about the medical terminologies, procedures followed, names of the drugs prescribed and their formulae, etc. and sometimes even extensive knowledge about the diseases and the related procedures conducted in order to transcribe with perfection. Typing the medical records requires lot of concentration also, for the doctors dictations may not be so clear, for they may dictate from anywhere. Only when the typing of medical records is perfect, the doctors may not come across with any problems in the future diagnosis and treatment of diseases for the concerned patient, if the records have to be referred in the future. It is also required for any legal issues which may arise in the future.

Nowadays, in the developing countries, the significance of medical transcription industry is well known. People have started learning medical transcription, and have even gone to the depth of obtaining the required certifications to shine well in the industry. Doctors also have an option to record their Medical Letters, and other Medical records through the dictation software available and convert them into the text through the transcription software available. But the accuracy of converting the Medical Letters and records to text is not guaranteed, when the software is used for transcribing. It is because the voice recording may not be clear for the software to recognize and transcribe. Due to this drawback, the health care industry as such prefers human intervention for typing the medical records, procedures, diagnostics, prescriptions, etc. in spite of using the software for recording the voice.