The Medical Transcriptionist is responsible for accurately transcribing, editing, and maintaining clinical documentation dictated by physicians and other healthcare providers to ensure complete, timely, and compliant patient medical records. This role supports the integrity of patient care documentation by identifying inconsistencies, researching clarification when needed, and collaborating with providers and staff to ensure accuracy. The Medical Transcriptionist also contributes to documentation quality, regulatory compliance, and continuous improvement of health information processes.
Essential Duties and Responsibilities:
- Produces accurate and timely medical reports, correspondence, records, patient records and other clinical and administrative documentation.
- Performs data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
- Returns dictated hospital and clinic reports in printed or electronic form for physicians' review, signature, and corrections, and for inclusion in patients' medical records.
- Distinguishes between similar-sounding terms and identifies inconsistencies or errors in medical language using appropriate reference materials.
- Identifies documentation errors and collaborates with providers to obtain clarification and ensure accuracy.
- Assists patients and others with the release of medical records.
- Assists with maintaining the IHIE inbox, provider direct email addresses for Meaningful Use, and setting up providers for Docs 4 Docs.
- Assists hospital outpatient departments with creating and maintaining patient packets and medical records.
- Participates in call time on weekends and holidays for medical transcription and other Health Information Management (HIM) records as needed.
- Protects patient privacy and confidentiality in accordance with HIPAA and privacy laws.
- Ensures patient satisfaction, including troubleshooting when there is a complaint and developing process improvements to prevent reoccurrences.
- Demonstrates clear ownership of workplace and patient safety.
- Report mistakes, near misses, adverse events and quality and safety concerns.
- Participates in the development and implementation of safety and quality improvement activities.
- Other duties as may be assigned.
Job Requirements
Education: High School Diploma or GED required.
Certification/Licensure: Certified medical transcriptionist (CMT) or certified healthcare documentation specialist (CHDS) preferred.
Experience: Three (3) years of previous experience as a Medical Transcriptionist required. Knowledge of medical terminology, anatomy and physiology. Knowledge of medical transcription guidelines and practices. Excellent skills in English usage, grammar, punctuation, and style. Ability to: use an extensive array of professional reference materials; operate word processing, dictation and transcription equipment; work independently with minimal or no supervision; work under pressure with time constraints. Excellent communication skills, especially listening, required.
Physical Requirements: Frequently sitting and typing for long periods of time. Occasionally lift up to 25 lbs. Ability to bend, stoop and reach. Good hearing acuity for transcribing dictation.
