9 Sep

The Evolution Of Medical Records

In the past, medical reports consisted of very abbreviated handwritten notes that were added in the patient’s file for interpretation by the primary physician responsible for the treatment. Ultimately, this mess of handwritten notes and typed reports was consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department.

Whenever the need arose to review the records of a specific patient, the patient’s file would be retrieved from the filing cabinet and delivered to the requesting physician. To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy.

It was in the 1960s when doctors and nurses began to realize there had to be a more efficient way to documents patients records. Shortly the evolution of medical transcription (MT) came to pass. The method was designed to assist in the manufacturing process. The first transcription was developed in 1975.

This process was known as Manufacturing Resource Planning (MRP). Today medical transcription is an allied health profession, which deals in the process of transcription, or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals, into text format.

From the early 1970s to now the industry has seen drastic changes in transcription equipment. It started with the change from manual typewriters to electric typewriters then from word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings. Today, speech recognition, also known as continuous speech recognition, is increasingly being used, with medical transcriptionists providing supplemental editorial services.

In recent years, medical records have changed considerably. Although many physicians and hospitals continue with the “old school” process of paper records, there is a drive for electronic records. Filing cabinets are giving way to desktop computers connected to powerful servers, where patient records are processed and archived digitally. This digital format allows for immediate remote access by any physician who is authorized to review the patient information.

Reports are stored electronically and printed selectively as the need arises. Many MTs now utilize personal computers with electronic references, and use the Internet not only for web resources but also as a working platform. Technology has gotten so sophisticated that MT services and MT departments work closely with programmers and information systems staff to stream in voice and accomplish seamless data transfers through network interfaces.

In fact, many healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants (PDAs), and are now utilizing software on them for dictation.