It contains up-to –date & confidential information of patient. The term 'transcript', 'report' or 'medical record' describes electronic or physical hard copy of data which is captured from the medical transcription process. This merged and larger patient medical record is commonly known as the patient's medical history.



In the past, these reporting consists of abbreviated and typical handwritten notes & that were added in the patient's file for future reference & treatment but it is very time consuming & typical process that’s why now in these days many health care providers are using the benefits of hand held PCs or personal data assistants (PDAs), and software for dictation.

As a professional transcriptionist must have knowledge of following points:

* Knowledge of basic to advanced medical terminology is essential.

* Strong verbal communication and memory skills.

* Ability to sort, checks, count, and verify numbers with accuracy.

* Demonstrated skill in the use and operation of basic office equipment/computer.

* Ability to follow verbal and written instructions.

* Records maintenance skills or ability.

* Good typing skills.

* Knowledge and experience transcribing of report work

* Knowledge of and proper application of grammar.

* Knowledge of and use of correct punctuation and capitalization rules.

MEDICAL TRANSCRIPTION SOFTWARE:-

This software is used to convert voice-recorded reports dictated by physicians or health care professionals into text format automatically. It is a universal, user-friendly, abbreviation expander program for the Windows operating system. MT software is most powerful & easy to use shortcut typing, even your e-mail and instant message boxes. This program can save 60% of your typing time. There are many types of MT software’s available in the market like Speed Type, Spectra Medi. etc. These software’s are also used for medical billing and coding for healthcare organizations.

Medical Transcription software based on three types of modules:

1) Input Modules

2) Core Modules

3) Output Modules

INPUT MODULES: input modules are designed to improve dictation services for high- and low-volume. These modules are easy-to-implement and easy-to-use.

OUTPUT MODULES:  output modules provide a full-set of extended transcription management features.

CORE MODULES: core module used to extend dictation and transcription services. It provides easy flow of data between input & output modules.

FEATURES:

1. A Medical Transcription Software should have capabilities of easy voice capture & Speech re-organization. With this medical transcriptionist can easily get doctor’s dictation with accuracy.

2. It should have ability of medical spell checking & dictionaries so that any coding specialist, who doesn’t have knowledge of medical terminology, can easily do transcriptions accurately & save time.

3. It should have easy document distribution. Medical transcription software provides documents available in a variety of formats and doctors can choose any of them.

4. It should provide variety of audio-video format which facilitates doctors to use different types of technology.

5. It should have feature of editing any interface quickly & accurately. It reduces turn around time.

6. It should be integrated with many healthcare systems & programs. It helps doctors & physicians to access data in readable form easily without wasting time.

7. Medical Transcription Software should have ability to work with medical billing & coding for healthcare organizations.