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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. Medical reports can be voice files, notes taken during a lecture, or other spoken material.
A medical scribe is an allied health paraprofessional who specializes in charting physician-patient encounters in real time, such as during medical examinations. They also locate information and patients for physicians and complete forms needed for patient care.
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
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.
This is a list of abbreviations used in medical prescriptions, including hospital orders (the patient-directed part of which is referred to as sig codes).This list does not include abbreviations for pharmaceuticals or drug name suffixes such as CD, CR, ER, XT (See Time release technology § List of abbreviations for those).
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]
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