Medical Scribe-Health Information Management

JOB DESCRIPTION

• Accompany physicians during patient visits to document real-time interactions and medical information directly into electronic health records.
• Prepare and assemble medical record documentation and charts for the physician before and after patient encounters.
• Accurately transcribe patient histories, physical examinations, procedures, lab results, and physician observations as dictated during the visit.
• 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 medico‑legal documents as necessary in an accurate and timely manner to document patient care.
• Applying 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 various accents, dialects and dictation styles utilizing in‑depth knowledge of medical transcription guidelines and practices.
• 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.
• Submitting all transcribed reports to the physician responsible for review, signature, correction, approval and insertion into the patient medical record.
• 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 line manager.
• Recognizing and reporting problems, errors and discrepancies in dictation and patient records to appropriate channels.
• Verifying patient information for accuracy and completeness utilizing the electronic medical record.
• Identifying and eliminating duplicate records both paper and electronic in the dictation system.
• Staying current with 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 daily. Keeping accurate work logs and editing 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.
• Participating in all team efforts as required.
• Collaborating with other members of the team to carry out work smoothly.

• Ensure completeness, accuracy, and timeliness of all medical documentation and patient records.
• Maintain compliance with hospital, clinic, and legal regulations, including HIPAA, DOH, and other accreditation standards.
• Support efficient clinic workflow and provider productivity by reducing the administrative burden on clinicians.
• Ensure all documentation is reviewed and authenticated by the physician.
• Maintain a high standard of professionalism, discretion, and patient privacy at all times.

• Proficiency in EHR systems and medical recording software.
• Strong knowledge of medical terminology, diagnoses, and procedures.
• Fast and accurate typing skills…