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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.
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 ...
Medical scribe. 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. Depending on which area of practice the scribe works in, the ...
Abbreviations are used very frequently in medicine. They boost efficiency as long as they are used intelligently. The advantages of brevity should be weighed against the possibilities of obfuscation (making the communication harder for others to understand) and ambiguity (having more than one possible interpretation).
1970–present. European Journal of General Practice. Family medicine. Taylor & Francis. English. 1995–present. European Journal of Medical Research. Clinical research. BioMed Central.
The main discussion of these abbreviations in the context of drug prescriptions and other medical prescriptions is at List of abbreviations used in medical prescriptions. Some of these abbreviations are best not used, as marked and explained here.
Documentation performed at the time of clinical point of care can be conducted using paper or electronic formats. This process aims to capture medical information pertaining to patient's healthcare needs. The patient's health record is a legal document that contains details regarding patient's care and progress.
A medical certificate or doctor's certificate [1] [2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [3] It can serve as a sick note ( UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition.