Medical Transcriptionist

Role Overview

Medical Transcriptionist at SEHA. This role transcribes dictated medical material into clear, accurate text to document patient care across multiple medical specialties.

Role Purpose

Transcribe dictated medical reports and documents into accurate, timely text using extensive knowledge of medical terminology, anatomy, physiology, and English language rules to ensure comprehensive and legible patient records.

Key Responsibilities

Transcription & Documentation

• Ensure transcription of all relevant medical material in accurate and timely manner.
• Transcribe 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 medicolegal documents as necessary.
• Apply extensive knowledge of medical terminology, pharmacology, anatomy, physiology, disease processes, signs and symptoms, and laboratory values related to specialty or specialties.
• Apply in-depth knowledge of medical transcription guidelines and practices.
• Translate dictated medical slang and abbreviations into their expanded form to ensure accuracy of patient and healthcare facility records.
• Clarify dictated information that is unclear or incomplete using 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.
• Utilize professional reference materials.
• Submit all transcribed reports to the responsible physician for review, signature, correction, approval and insertion into the patient medical record.

Quality Assurance & Accuracy

• Ensure accuracy of report header and footer and correctness of 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 dictation without altering meaning or changing originator's style.
• Recognize and report unusual circumstances or information with possible risk factors to appropriate Senior Medical Transcription Officer.
• Recognize and report problems, errors and discrepancies in dictation and patient records to appropriate Senior Medical Transcription Officer.
• Verify patient information for accuracy and completeness using the electronic medical record.
• Ensure transcribed document is consistent with all recognized standards.

Data Management & Tracking

• Update deficiency tracking module when deficiency status changes, such as operative report or discharge summary status changing from "dictation required" to "signature required."
• Identify and eliminate duplicate records both paper and electronic in the dictation system.

Performance & Productivity

• Perform daily, weekly and monthly productivity reports for statistical purposes.
• Record productivity and ensure quality monitoring on a daily basis.
• Keep accurate work logs and edit sheets.
• Ensure electronic record of dictations is kept accurate.
• Stay current with clinical terminologies through publications, seminars, continuing education programs and other changes in the medical industry.

Equipment & Technical Support

• Operate word processing equipment, dictation and transcription equipment and other equipment as specified.
• Troubleshoot equipment as necessary.
• Provide technical expertise in identifying potential issues.
• Discuss with Senior Medical Transcription Officer if necessary before recommending solutions after obtaining and verifying information.

Customer Service & Collaboration

• Respond to verbal and written inquiries in a timely manner.
• Participate in all team efforts as required.
• Collaborate with other members of the team to carry out work smoothly.

Qualifications & Experience

• 2 to 4 years of medical transcription experience in an acute care hospital setting or comparable setting.
• Desired: Experience in a large healthcare facility.