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Medical transcription editing is the process of listening to a voice-recorded file and comparing that to the transcribed report of that audio file, correcting errors as needed. Although speech recognition technology has become better at understanding human language, editing is still needed to ensure better accuracy.
Sample view of an electronic health record. An electronic health record (EHR) also known as an electronic medical record (EMR) or personal health record (PHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings.
Dictation of reports can be integrated into a single system. Integrated speech-to-text voice recognition software may be used to create and upload a report to the patient's chart within minutes of the patient's scan, or the reporting physician may dictate their findings into a phone system or voice recorder.
Radiopaedia is a wiki-based international collaborative educational web resource containing a radiology encyclopedia and imaging case repository. [1] It is currently the largest freely available radiology related resource in the world with more than 50,000 patient cases and over 16,000 reference articles on radiology-related topics.
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
determination of sperm count and motility in a sample taken from the cervical canal within an hour of intercourse: Sister Mary Joseph nodule [7] Sister Mary Joseph Dempsey (born Julia Dempsey) oncology: various abdominal malignancies: palpable lymph node in the umbilicus Spurling's test: Roy Glenwood Spurling: neurology: cervical radiculopathy
The adoption of structured reporting aimed to standardize reports to be concise and uniform, influencing patient care. The introduction of BI-RADS (Breast Imaging–Reporting and Data System) is a notable example, which has led to improved consistency across mammography reports. This milestone spans several years as these systems were refined ...