Medical Transcription has existed since the beginning of medical care and research.

Ancient cave writings attest to the earliest forms of healthcare documentation. While the medium changed from metal plates to clay tablets, to hieroglyphs on temple walls, to papyrus, to parchment, to paper, and most recently to electronic files, the reasons for maintaining records have always been the same - to record an individual's health care and the achievements in medical science.

Until the twentieth century, physicians served as both providers of medical care and scribes for the medical community. After 1900, when standardization of medical data became critical to research, medical stenographers replaced physicians as scribes, taking their dictation in shorthand.

The advent of dictating equipment made it unnecessary for physician and scribe to work face-to-face, and the career of medical transcription began. As physicians came to rely on the judgment and reasoning of experienced medical transcriptionists to safeguard the accuracy and integrity of medical dictation, medical transcription evolved into a medical language specialty. Now, at the dawn of the twenty-first century, medical transcriptionists are using speech recognition technology to help them create even more documents in a shorter time. Medical transcription is one of the most sophisticated of the allied health professions, creating an important partnership between healthcare providers and those who document patient care.

Medical Transcriptionists as Professionals
Since 1978, medical transcriptionists have been represented by a professional organization, the American Association for Medical Transcription (AAMT), which has developed a competency profile (COMPROŽ) and a model curriculum for transcription educators, as well as a model job description. AAMT emphasizes continuing education for its members, holding an annual conference for medical transcriptionists, educators, supervisors and managers, and business owners. There are over 135 component associations of AAMT, each of which holds regular educational meetings and symposia.
Through the efforts of AAMT, medical transcriptionists have become recognized as healthcare professionals with expertise in medical language.

In the broadest sense, medical transcription is the act of translating from oral to written form (on paper or electronically) the record of a person's medical history, diagnosis, prognosis, and outcome.

The industry is moving toward electronic health records, allowing storage of an individual's health history so that it can be accessed by physicians and healthcare providers anywhere.

Physicians and other healthcare providers employ state-of-the-art electronic technology to dictate and transmit highly technical and confidential information for their patients. These medical professionals rely on skilled medical transcriptionists to transform spoken words into comprehensive records that accurately communicate medical information. Sometimes speech recognition systems are used as an intermediary to translate the medical professional's dictation into rough draft. The medical transcriptionist then further refines it into a finished document.

Keyboarding and transcription should not be confused. The primary skills necessary for performance of quality medical transcription are extensive medical knowledge and understanding, sound judgment, deductive reasoning, and the ability to detect medical inconsistencies in dictation. For example, a diagnosis inconsistent with the patient's history and symptoms may be mistakenly dictated. The medical transcriptionist questions, seeks clarification, verifies the information, and enters it into the report.

What does a medical transcriptionist need to know?
Medical understanding is critical for the professional medical transcriptionist. The complex terms used in medicine are unlike the language of any other profession.

Medical transcription requires a practical knowledge of medical language, anatomy, physiology, disease processes, pharmacology, laboratory medicine, and the internal organization of medical reports. A medical transcriptionist is truly a medical language specialist who must be aware of standards and requirements that apply to the health record, as well as the legal significance of medical transcripts.

Reports of patient care take many forms, including histories and physical examinations, progress reports, emergency room notes, consultations, operative reports, discharge summaries, clinic notes, referral letters, radiology reports, pathology reports, and an array of documentation spanning more than 60 medical specialties and subspecialties! Thus, the medical transcriptionist, or medical language specialist, must be well versed in the language of medicine.

To prepare for this profession, medical transcriptionists study: