Clinical documentation has been around for centuries. There are records from the 18th and 19th centuries that show the detailed observation and findings recorded by doctors of that time. However, clinical documentation has undergone drastic changes over the years. In the early days, clinical documentation was used as a record of the patient’s diagnosis and treatment for future reference.
Medical transcription is an integral aspect of a physician’s practice, which involves processing a physician’s dictations into written documents. These transcripts ought to adhere to a number of regulations and laws set by the HIPPA Act, thus resulting in a degree of uniformity across practices. Medical transcriptions have hence improved a lot since their inception,