Medical records have become central to nearly all aspects of healthcare. However, little research exists on their creation. Using data from an ongoing ethnographic study of healthcare documentation production, this paper examines the process of medical record creation through the use of speech recognition technology (SRT) and subsequent editing by medical transcriptionists (MTs). Informed by ethnomethodology (EM) and conversation analysis (CA), the results demonstrate the professional knowledge involved in the work of medical transcription, which includes a combination of skilled worksite practices and an orientation toward the social order properties of recorded dictation. Furthermore, we examine how the advantages and limitations of SRTs can impact the work of transcription. We conclude with strategic recommendations for using SRTs to support medical records production and recommend against total automation.

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http://dx.doi.org/10.1111/j.1467-9566.2009.01186.xDOI Listing

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