Medical Scribe-Health Information Management - UAE National

Role Overview

Medical Scribe-Health Information Management at Sheikh Shakhbout Medical City (SSMC), located in the UAE.

Company Overview

Sheikh Shakhbout Medical City (SSMC) is the largest tertiary hospital in the UAE, serving to elevate the provision of health care services under the mandate of the Abu Dhabi Economic Vision 2030. SSMC offers care in 44 specialties with 742 patient beds, 18 operating theatres, a hybrid operating room, a 26-bed neonatal intensive care unit, and the UAE's largest pathology lab. A team of locally and internationally trained medical, clinical and administrative professionals work seamlessly together to deliver comprehensive interdisciplinary learning and integrated patient-centric medical services in the region.

Role Purpose

The Medical Scribe supports efficient clinic workflow and provider productivity by accompanying physicians during patient visits to document real-time interactions and medical information directly into electronic health records, while maintaining the highest standards of accuracy, completeness, timeliness, and patient privacy.

Key Responsibilities

Documentation & Transcription

• 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.
• Ensure transcription of all medical reports including discharge summaries, operative reports, cardiology reports, electroencephalogram (EEG) reports, pathology reports, medical evaluations, history and physical reports, consultation notes, progress notes and other medico-legal documents in an accurate and timely manner.
• Translate dictated medical slang and abbreviations into their expanded form to ensure accuracy of patient and health care facility records.

Quality Assurance & Accuracy

• Apply knowledge of medical terminology, pharmacology, anatomy and physiology, disease processes, signs and symptoms, laboratory values related to specialties and English language rules to transcription and proofreading of medical dictation from originators with various accents, dialects and dictation styles.
• Ensure accuracy of header and footer and correctness of the body of transcribed material.
• Ensure correct spelling of medical terms, correct punctuation, and grammar.
• Ensure proper identification of patient name and medical record number.
• Identify, interpret and evaluate inconsistencies, discrepancies and inaccuracies in medical dictation; appropriately edit, revise and clarify them without altering the meaning of the dictation or changing the originator's style.
• Verify patient information for accuracy and completeness utilizing the electronic medical record.
• Ensure that transcribed documents are consistent with all recognized standards.
• Record productivity and ensure quality monitoring daily, keeping accurate work logs and editing sheets and ensuring the electronic record of dictations is kept accurate.

Clarification & Verification

• Clarify dictated information that is unclear or incomplete, utilizing the electronic medical record to confirm laboratory and radiology results, diagnoses and medication dosages.
• Seek assistance from physicians, nursing units, offices and ancillary departments as necessary.
• Identify and eliminate duplicate records both paper and electronic in the dictation system.

Compliance & Risk Management

• 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.
• Ensure all documentation is reviewed and authenticated by the physician.
• Recognize and report unusual circumstances and information with possible risk factors to line manager.
• Recognize and report problems, errors and discrepancies in dictation and patient records to appropriate channels.
• Maintain a high standard of professionalism, discretion, and patient privacy at all times.

Administrative & Technical Operations

• Submit all transcribed reports to the physician responsible for review, signature, correction, approval and insertion into the patient medical record.
• Operate word processing equipment, dictation and transcription equipment and other equipment as specified and troubleshoot as necessary.
• Respond to verbal and written inquiries in a timely manner.
• Provide technical expertise in identifying potential issues.

Professional Development & Collaboration

• Stay current with clinical terminologies through publications, seminars, continuing education programs and other changes in the medical industry.
• Participate in all team efforts as required.
• Collaborate with other members of the team to carry out work smoothly.

Qualifications & Experience

Education

• Bachelor's degree in health information management or relevant field, or Diploma with 3 years of additional experience.

Experience

• UAE Nationals only.
• 2–4 years of medical transcription experience in an acute care hospital setting or comparable setting.
• Experience in a large healthcare facility is desired.

Certifications

• Certification as a Certified Medical Transcriptionist or equivalent is desired.

Skills & Competencies

• Proficiency in EHR systems and medical recording software.
• Strong knowledge of medical terminology, diagnoses, and procedures.
• Fast and accurate typing skills (typically 60–80 words per minute).
• Excellent written and verbal communication skills.
• Strong organizational, multitasking, and time management abilities.
• Ability to work in high-pressure, fast-paced clinical environments.
• Good interpersonal skills for working alongside providers and interacting with patients.
• High attention to detail and accuracy in documentation.
• Adaptability to different providers, specialties, and clinical settings.

Additional Information

• UAE National candidates only.