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Job Description Responsible for transcribing dictated material into clear and understandable text for the purpose of documenting patient care.
Responsibilities
Key Responsibilities of the role
Key Responsibilities of the role Corresponding Key Activities performed by the role
Ensuring transcription of all relevant material
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 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 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. Utilization of professional reference materials.
Submitting all transcribed reports to the responsible physician 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 reports
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.
Deficiency Tracking Ensure deficiency tracking module is updated when the deficiency status changes, i.e. a operative report or discharge summary status changes from “dictation required” to “signature required.
Data Management Identifying and eliminating duplicate records both paper and electronic in the dictation system
Maintaining performance standards
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
Performing daily, weekly, and monthly productivity report for statistical purposes
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.
Providing customer service and support
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
Contributing to the team effort
Participating in all team efforts as required
Collaborating with other members of the team to carry out work smoothly
Facility specific Responsibilities of the role Corresponding Activities performed by the role
Qualifications
Required:
Bachelor in Health Information Management or relevant field or Diploma with 3 years of additional experience
Desired
Bachelor’s degree in a related field
