Medical transcriptionists listen to voice recordings that physicians and other healthcare professionals make and convert them into written reports. They may also review and edit medical documents created using speech recognition technology. Transcriptionists interpret medical terminology and abbreviations in preparing patients' medical histories, discharge summaries, and other documents.
Essential Functions:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Listen to the recorded dictation of a doctor or other healthcare professional
Transcribe and interpret the dictation into diagnostic test results, operative reports, referral letters, and other documents
Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and has a consistent style
Translate medical abbreviations and jargon into the appropriate long form
Identify inconsistencies, errors, and missing information within a report that could compromise patient care
Follow up with the healthcare provider to ensure the accuracy of the reports
Submit health records for physicians to approve
Follow patient confidentiality guidelines and legal documentation requirements
Enter medical reports into electronic health records systems
Perform quality improvement audits
Answer phone calls and respond to emails related to transcription tasks
Other duties as assigned.
High School Diploma or GED
Registered Healthcare Documentation Specialist (RHDS) certification or Certified Healthcare Documentation Specialist (CHDS) certification
Computer Skills
Critical-thinking skills
Listening Skills
Time management skills
Writing skills
Competencies:
Critical Thinking - Ability to identify inconsistencies and errors in documentation that could impact patient care and to resolve them appropriately.
Listening Skills - Listens attentively to dictated recordings and accurately transcribes verbal information.
Time Management - Efficiently manages workload and meets documentation deadlines.
Writing Skills - Demonstrates proper grammar, punctuation, and medical terminology usage to produce clear, professional documentation.
Attention to Detail - Carefully reviews documents for completeness and accuracy.
Confidentiality - Maintains patient privacy and complies with legal and ethical standards of documentation.