Medical Scribe-Health Information Management

JOB DESCRIPTION

• 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.

• 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

medico legal documents as necessary in an accurate and timely manner to document patient

care.

• Applying 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.

• Submitting all transcribed reports to the physician responsible for review, signature,
  
  

Job Description

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 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 line manager.

• Recognizing and reporting problems, errors and discrepancies in dictation and patient records
  
  

to appropriate channels.

• Verifying patient information for accuracy and completeness utilizing the electronic medical
  
  

record.

• Identifying and eliminating duplicate records both paper and electronic in the dictation system
• Staying current with 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
• Recording productivity and ensuring quality monitoring daily. Keeping accurate work logs and
  
  

editing sheets and ensuring the electronic record of dictations is kept accurate.

• Responding to verbal and written inquiries in a timely manner
• Providing technical expertise in identifying potential issues
• Participating in all team efforts as required
• Collaborating with other members of the team to carry out work smoothly
  
  

Accountabilities

• 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.

• Support efficient clinic workflow and provider productivity by reducing the administrative
  
  

burden on clinicians.

• Ensure all documentation is reviewed and authenticated by the physician.
• Maintain a high standard of professionalism, discretion, and patient privacy at all times.
  
  

RESPONSIBILITIES

• 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.
  
  

QUALIFICATIONS

Education, Certifications, and Professional Experience (Required for satisfactory performance on the job)

Required:

• Bachelor’s in health information management or relevant field or Diploma with 3 years of
  
  

Desired:

additional experience

• Bachelor’s degree in a related field
  
  

Required:

Specialist Certifications:

N. A.

Desired:

• Certification as a Certified Medical Transcriptionist, or equivalent
  
  

Experience:

Required:

• 2 – 4 years of medical transcription experience in an acute care hospital setting or comparable
  
  

setting.

Desired:

• Experience in a large healthcare facility