Medical Transcriptionist

Overview

The primary function of the medical transcriptionist is to enter patient demographic data and final diagnosis into the laboratory information system (LIS). After the data entry process is completed, the medical transcriptionist returns the electronic files to the health professionals for correction and signatures. These documents are very important because they become a part of the patients’ permanent medical file. The transcriptionist will also be responsible for filing slides and paperwork, responding to material requests from outside institutions, sending cases for consult or further testing, ensuring that reports are faxed to PCPs, and other office work. Strong typing skills and an ability to multi-task are key.

Responsibilities

• Decide which information should be included or excluded in reports.
• Distinguish between homonyms, and recognize inconsistencies and mistakes in medical terms, referring to dictionaries, drug references, and other sources on anatomy, physiology, and medicine.
• Identify mistakes in reports, and check with doctors to obtain the correct information.
• Perform data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
• Produce medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
• Return dictated reports in printed or electronic form for physicians' review, signature, and corrections, and for inclusion in patients' medical records.
• Review and edit transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology.
• Take dictation using either shorthand or a stenotype machine, or using headsets and transcribing machines; then convert dictated materials or rough notes to written form.
• Transcribe dictation for a variety of medical reports such as patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation, and/or discharge summaries.
• Translate medical jargon and abbreviations into their expanded forms to ensure the accuracy of patient and health care facility records.
• Answer inquiries concerning the progress of medical cases, within the limits of confidentiality laws.
• Perform a variety of clerical and office tasks, such as handling incoming and outgoing mail, completing and submitting insurance claims, typing, filing, and operating office machines.
• Maintain patient records.
• Set up and maintain medical files and databases that may incldue records such as x-ray, lab, and procedure reports, medical histories, diagnostic workups, admission and discharge summaries, and clinical resumes.
• Maintains a ONETeam mindset using the foundation of our core values, the 3Ps: Positivity, Productivity, and Professionalism.
• Support APDerm’s mission and culture of high-quality standards by carrying out applicable policies, procedures and established industry standards, laws and regulations. Examples include adhering to privacy and data protection practices, ensuring a safe workplace, and reporting observed or suspected behavior and actions that do not meet APDerm standards.
• Complete all assigned required training by the deadline including, but not limited the Code of Conduct, Privacy & Data Security, and OSHA.

Qualifications

• Associate's or bachelor's degree in healthcare administration preferred.
• 1 Year Medical Office Experience / Reception / CMA Experience
• 2 Years Administrative experience
• 2 Years Customer Service

Preferred• Bachelor’s degree in Healthcare Administration, Business or related field