The process of medical treatments given to patients has been documented since the early ages to record findings in a quest to find solutions for human ailments. Ways and means of recording these medical documents have since evolved.

The early stages of modern medical care saw doctors themselves make notes about the patients' treatments which diverted quite a large amount of patient-care time towards record upkeep which though essential was disadvantageous to both patients and doctors. To change this, doctors making dictations about the treatment process came into practice. These dictations were handled by in-house staff and recorded as Word documents. Outsourcing of this work saw the emergence of medical transcription services.

EHRs, though it existed since the 1960s, not until the Health Insurance Portability and Accountability Act (HIPAA) was established in 1996, was there a shift towards working with EHRs. Medical transcription companies at this time made the shift from typing into Word documents to making records directly into the EHRs. It follows structured templates and drop-down menus that contain all that is needed to create a proper medical document. This led to the standardization of work for medical transcriptionists on a global level.