There are a variety of medical reports generated every day in physician offices, clinics, and hospitals. Medical transcriptionists should be familiar with those dictated in each work setting. Physicians in private practice frequently dictate office chart notes, letters, initial office evaluations, and history and physical examinations. Medical reports dictated in hospitals and medical centers are numerous in category.

The healthcare record is chronological, documented evidence of a patient's initial database, initial evaluation, identified problems and needs, objectives of care, prescribed treatment, and end results. The record may be paper, stored digitally in electronic format in a computer jobs, or a combination of the two. The healthcare record is the property of the hospital, medical facility, or office in which it was originated, and it cannot be removed from the premises without a subpoena or court order. It is maintained in a Health Information Department usually headed by an RRA.

A discussion of medical transcription equipment should begin with the most important but often overlooked asset...the human brain. The machines used in medical transcription today are simple devices, and without human knowledge and intervention, machines are basically useless. The transcriptionist is the brain of the machine. Dictation systems: As physicians depend on their stethoscopes, scalpels, and tongue depressors, medical transcriptionists.