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Medical transcription, also known as MT, is an allied health profession dealing with the process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners.
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
The difference between AI medical scribes and human scribes, who physically accompany healthcare providers during patient visits, AI scribes typically operate in the background usually on the providers device. AI medical scribes although do parts of the job description of a traditional medical scribe, cannot do everything.
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
The abstraction phase involves reading the entire record of the health encounter and analysing the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical record, such as clinical notes, laboratory and radiology results, and operation ...
A job description or JD is a written narrative that describes the general tasks, or other related duties, and responsibilities of a position. It may specify the functionary to whom the position reports, specifications such as the qualifications or skills needed by the person in the job, information about the equipment, tools and work aids used, working conditions, physical demands, and a ...