As an important component of the healthcare industry, medical transcriptionists transcribe doctors’ notes, findings and patient information in predefined databases.
This information is vital to the patient treatment which is why it needs to be accurate.
These professionals are required to be knowledgeable of medical terminology and possess excellent typing skills as they need to type a vast amount of data each day.
Typically, medical transcriptionists listen to recordings and type the text into either a word processor or a database depending on the type of information in question.
There are many different types of documents that they transcribe including discharge summaries, medical histories, consultation reports and autopsy reports.
They also manage transcribing duties for diagnostic imaging studies and referral letters. Once they are done with a transcription project, they need to obtain doctors’ signatures to ensure that the information is correct. Once this is done, the transcript is ready to be added to the patient’s file.
See also: Medical Transcriptionist Resume
• Collect patients’ histories, physicals, consults and test results from doctors.
• Proofread information obtained from doctors to ensure accuracy.
• Listen to recordings and obtain information that needs to be transcribed.
• Verify accuracy of patient records.
• Type information by listening to recordings.
• Make the decision on which information to include as part of the transcript.
• Recognize inconsistencies in information and report them to doctors.
• Refer to dictionaries and other resources to confirm medical terms
• Perform data entry and data retrieval duties.
• Manage production of medical reports and patient care information
• Review transcribed reports and make any additions or deletions as and when necessary.
• Ensure appropriate translation of medical jargon and abbreviations.
• Answer questions regarding the progress of medical transcriptions.
• Answer telephones to assist with providing information to patients and doctors.
• Route and print transcribed reports when prompted.
• Provide clerical support to other staff such as pathologists and laboratory personnel.
• Document all procedures performed by healthcare professionals.
• Record provider dictated diagnosis for patient discharge.
• Maintain medical files such as x-ray and lab reports and diagnostic workups.
• Manage admission and discharge summaries along with handling clinical resumes.
• Take dictation from doctors and produce documents conducive to the information provided.
• Edit and proofread information on patients’ files.
• Manage operative reports and letters by filing them appropriately.