Medical Transcriptionist-Health Information Management

JOB DESCRIPTION

Responsible for transcribing dictated material into clear and understandable text for the purpose of documenting patient care.

• Ensuring transcription of all medical reports (discharge summaries, operative reports, cardiology reports, electroencephalogram reports, pathology reports, medical evaluations, history and physical reports, consultation notes, progress notes, and other medicolegal documents) in an accurate and timely manner to document patient care.
• 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 various accents, dialects and dictation styles, utilizing in‑depth knowledge of medical transcription guidelines and practices. Translating dictated medical slang and abbreviations into their expanded form to ensure accuracy.
• 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. Utilization of professional reference materials.
• Uploading all the transcribed medical reports into the electronic medical record for review, modification/correction if required, and electronic authentication of the 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 the appropriate Senior Medical Transcription Officer.
• Recognizing and reporting problems, errors and discrepancies in dictation and patient records to the appropriate Senior Medical Transcription Officer.
• Verifying patient information for accuracy and completeness utilizing the electronic medical record.
• Ensuring the deficiency‑tracking module is updated when the deficiency status changes, for example, when an 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 the 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 the 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.

Required:

• 2–4 years of medical transcription experience in an acute care hospital setting or comparable setting.

Desired:

• Experience in a large healthcare facility.

Educational Qualification –

Required:

• Bachelor’s degree in Health Information Management or a diploma with 3 additional years of experience.

Desired:

• Bachelor’s degree in a related field.

At SSMC, we firmly believe that the human touch is a fundamental part of care. We understand that health care is…