Medical Transcriptionist-Health Information Management
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Key skills for this role
About the Role
Responsible for accurate medical report transcription, utilizing medical terminology knowledge, ensuring quality, and collaborating with healthcare teams.
Key Skills for This Role
Responsibilities
- Transcribe medical reports including discharge summaries, operative reports, and cardiology reports
- Proofread and edit medical dictation for accuracy and completeness
- Upload transcribed reports into electronic medical records for physician review
- Clarify unclear dictation by consulting physicians or using medical records
- Maintain accurate work logs and quality monitoring records
Requirements
- Knowledge of medical terminology, pharmacology, anatomy and physiology
- Experience with electronic medical records
- Proficiency in English language rules
- Ability to operate dictation and transcription equipment
Full Job Posting
Job Overview
- Ensuring transcription of all medical reports e.g. discharge summaries, operative reports, cardiology reports, electroencephalogram (EEG) reports, pathology reports, medical evaluations, history and physical reports, consultation notes and progress notes and other medicolegal documents as necessary
Key Responsibilities
- Applying extensive knowledge of medical terminology, pharmacology, anatomy and physiology, disease processes, signs and symptoms, laboratory values related to a specialty or specialties and English language rules to the transcription and proofreading of medical dictation from originators with variou
- Translating of dictated medical slang and abbreviations into their expanded form to ensure the accuracy of the patient and health care facility records.
- Clarifying dictated information that is unclear or incomplete, utilizing the electronic medical record to confirm laboratory and radiology results, diagnoses and medication/dosages and seeking assistance from physicians, nursing units, offices and/or ancillary departments as necessary.
- Uploads all the transcribed medical reports in to the electronic medical record for the review, modification/correction if required and electronic authentication of responsible physician.
- Operating word processing equipment, dictation and transcription equipment and other equipment as specified and troubleshooting as necessary.
- Ensuring accuracy of the header and footer, and the correctness of the body of the transcribed material
- Ensuring correct spelling of medical terms, correct punctuation, and grammar
- Ensuring proper identification of patient name and medical record number
- Identifying, interpreting and evaluating inconsistencies, discrepancies and inaccuracies in medical dictation; appropriately editing, revising and clarifying them without altering the meaning of the dictation or changing the originator's style.
- Recognizing and reporting unusual circumstances and/or information with possible risk factors to appropriate Senior Medical Transcription Officer.
- Recognizing and reporting problems, errors and discrepancies in dictation and patient records to appropriate Senior Medical Transcription Officer.
- Verifying patient information for accuracy and completeness utilizing the electronic medical record.
Qualifications
- Ensures deficiency tracking module is updated when the deficiency status changes, i.e. operative report or discharge summary status changes from Pending Dictation to Pending signature.
- Identifying and eliminating duplicate records both paper and electronic in the dictation system
- Staying current with the clinical terminologies through publications, seminars, continuing education programs and other changes in the medical industry
- Ensuring that transcribed document is consistent with all recognized standards
- Recording productivity and ensuring quality monitoring on a daily basis. Keeping accurate work logs and edit sheets and ensuring the electronic record of dictations is kept accurate.
- Responding to verbal and written inquiries in a timely manner
- Providing technical expertise in identifying potential issues
- Discussing with Senior Medical Transcription Officer (if necessary) before recommending solutions after obtaining and verifying information
- Participating in all team efforts as required
- Collaborating with other members of the team to carry out work smoothly
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