Medical Transcriptionist (Sakina)

Responsible for transcribing dictated material into clear and understandable text for the purpose of documenting patient care.

Corresponding Key Activities performed by the role

Ensuring transcription of all relevant material

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 medicolegal documents as necessary in an accurate and timely manner to document patient care.

Applying extensive 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.

Utilization of professional reference materials.

Submitting all transcribed reports to the responsible physician for review, signature, 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 reports

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 appropriate

.

Recognizing and reporting problems, errors and discrepancies in dictation and patient records to appropriate

.

Verifying patient information for accuracy and completeness utilizing the electronic medical record.

Ensure deficiency tracking module is updated when the deficiency status changes, i.e. a operative report or discharge summary status changes from “dictation required” to “signature required.

Identifying and eliminating duplicate records both paper and electronic in the dictation system

Maintaining performance standards

Staying current with the 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

Performing daily, weekly, and monthly productivity report for statistical purposes

Recording productivity and ensuring quality monitoring on a daily basis.

Keeping accurate work logs and edit sheets and ensuring the electronic record of dictations is kept accurate.

Providing customer service and support

Responding to verbal and written inquiries in a timely manner

Providing technical expertise in identifying potential issues

Discussing with

(if necessary) before recommending solutions after obtaining and verifying information

Contributing to the team effort

Participating in all team efforts as required

Collaborating with other members of the team to carry out work smoothly

Facility specific Responsibilities of the role

Corresponding Activities performed by the role

Bachelor in Health Information Management or relevant field or Diploma with 3 years of additional experience

Bachelor’s degree in a related field