Medical Scribe-Health Information Management

• 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.