• Listen to the recorded dictation of a doctor or other healthcare professional.
• Transcribe and interpret the dictation into diagnostic test results, operative reports, referral letters, and other documents.
• Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and has a consistent style.
• Translate medical abbreviations and jargon into the appropriate long form.
• Identify inconsistencies, errors, and missing information within a report that could compromise patient care.
• Follow up with the healthcare provider to ensure the accuracy of the reports.
• Submit health records for physicians to approve.
• Follow patient confidentiality guidelines and legal documentation requirements.
• Enter medical reports into electronic health records systems.
• Perform quality improvement audits.
• Performs other duties as assigned or required.
• Must be at least graduate.
• Medical Transcription training/certification will be a plus.
• Proficient in medical terminology, anatomy and physiology, clinical medicine, surgery, diagnostic tests, radiology, pathology, pharmacology, and various medical specialties as required in areas of responsibility.