Medical Language specialist (or healthcare documentation specialists) who interprets and transcribes clinical dictation by physicians and other healthcare professionals regarding patient assessment, workup, therapeutic procedures, clinical course, diagnosis, prognosis, etc., in order to document patient care and facilitate delivery of healthcare services and for medico-legal purposes. Listen to voice recordings that physicians and other healthcare workers make and convert into transcribed reports. May also review and edit medical documents created using speech recognition technology. Compliance with all applicable State and Federal laws, regulations, and policies governing the provision of health care. Adheres to guidelines as published in "AAMT Book of Style".
- Meets Copley Hospital standards related to: telephone etiquette, customer service, inter/intra departmental relations, confidentiality, corporate compliance and quality.
- Supports organizational values: compassion and respect, commitment to professional competence. Abides by the Code of Conduct.
- Knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values related to a specialty of specialties. Interpret medical terminology and abbreviations in preparing patient's records.
- In-depth knowledge of medical transcription guidelines and practices.
- Ability to use a vast array of professional reference materials, often in innovative ways. Detect errors and inconsistencies in medical terminologies and use dictionaries, libraries, drug references, and other sources of knowledge to ensure document produced is error free.
- Excellent written and oral communication skills; grammar, punctuation and style.
- Ability to operate word processing equipment, dictation and transcription equipment, and other equipment as specified, and to troubleshoot as necessary.
- Proven business skills (scheduling and prioritizing work,). Answer telephones in order to assist with providing information to physicians and healthcare workers.
- Ability to understand and apply relevant legal concepts (e.g. confidentiality).
- Adheres to Patient Identification Policy, verifies medical record number, patient name, date of birth, date of service, correct designation of report type and physician.
- Recognizes inconsistencies, discrepancies and inaccuracies in clinical dictation and edits/revises as needed without altering the meaning or content of the report. Follows protocol for making any corrections/revisions. Reports any concerns/issues to Lead Transcriptionist or Manager.
- Transcription ratio: The quantity is 133 lines per hours. The ratio is 4:1, expectation is that dictated reports will be transcribed in order of priority of work type assigned.
- Route and print transcribed reports when prompted.
- Meets quality and productivity standards and deadlines established for transcribed reports.
- Communicates with internal and external customers and management in an accurate, timely manner. Protects confidentiality, attend and participate in department and sections meetings.
- Manages self and resources effectively. Accepts changes in assignment, requests assistance appropriately.
- Participates in continuing education as needed to gain additional skills as may be required to perform job functions.
Education Requirements:High school graduate, associate degree or equivalent.
Multi-specialty transcription with digital dictation equipment, keyboarding. Three to six months medical transcription in acute care setting.
One year experience as medical transcriptionist in acute care setting.
License and Certification Desired:
CMT status preferred.
Operates designated word processing, dictation and transcription equipment as directed. Ability to type and transcribe 60 wpm. Knowledge of medical terminology, anatomy and physiology, clinical medicine, surgery, diagnostic tests, radiology, pathology, pharmacology and the various medical specialties. Ability to work under pressure within time constraints. Ability to clarify dictation which is unclear or incomplete. Ability to maintain strict confidentiality and security standards. Verified patient information for accuracy and completeness. Uses reference materials to ensure accuracy. Flags reports requiring attention of the supervisor.