The position of medical transcriptionist is mainly responsible for listening to physicians’ and healthcare providers’ notes carefully, recording and transcribing the same with accuracy. It is usually based in a healthcare setting.
The data transcribed by medical transcribers is used for generating discharge summaries, medical reports and patient histories.
Take a look at the following list of duties and tasks of a medical transcriptionist.
• Interpret, transcribe and verify dictations from physicians and consultant doctors
• Compile and document data regarding patient assessment, work-up, therapeutic procedures, diagnosis and prognosis for facilitation of medical record keeping
• Edit the transcribed data to make any corrections needed
• Conduct departmental productivity analysis on basis of collected statistical data
• Write out video and audio recordings of medical procedures, turning them into complete medical records for the management
• Document treatment procedures accurately for clarity, case follow up and educational purposes
• Collect prerecorded material and check the same for clarity, accuracy and accessibility
• Check transcribed copies against the recorded ones to ensure accuracy
• Transcribe verbatim carefully without misinterpretations or errors that could change the message
• Transcribe, organize, arrange and submit patients’ records timely to the record keeping department
• Simplify medical jargons and abbreviations into easily comprehendible language for non-medical professionals to carryout data processing and case documentation
• Get the documents reviewed and verified by the dictator before forwarding them to the respective department
• Consult doctors, libraries, medical vocabulary lists to differentiate between homonyms and detect and rectify and inconsistencies in the text transcribed
• Ensure data integrity and document confidentiality at all times
• Categorize various cases using well defined medical coding systems to archive the same in relevant areas of specialization, making data retrieval easy
• Verify patient information, ID details and details of the procedure given
• Follow legal requirements for release of case related information and issue the same only in case of authorization
• Maintain logs of cases transcribed, incoming dictations and reports issued on daily basis
• File all records after organizing completing and verifying the same
• Prepare, assemble and submit printed reports of dictated material for physicians’ review and include the same in patients’ medical file after verification by the dictating healthcare professional
• Proofread and edit transcribed data for grammatical or punctuation related errors
• Use shorthand, stenotype machines or dictation headsets to ensure accuracy and correctness of transcribed content
• Maintain correspondence with data retrieval department regarding authorization of medical data retrieval
• Issue discharge summaries, medical histories and physical examination reports in light of the transcribed data
• Use appropriate medical terminology to effectively convey the diagnosis, prognosis and recommended treatment plan by the doctor in an objective manner.