A Medical Transcriptionist listens to sound recordings made by physicians and other healthcare professionals, transcribes the recordings and creates written reports and documents from them. Uses medical terminology and abbreviations and operates recording equipment and software. Works in hospitals or medical offices, or for companies that provide transcription services to healthcare facilities.
Responsible for documenting patient history (including social, family, and past medical), medications, physical examination, review of systems as dictated by the provider in the patient room. Provides information regarding labs, imaging, referrals or any other pertinent information needed by the provider in the exam room. Conveys a positive image of clinic.
SUPERVISION RECEIVED
: Reports to Physician or Office Manager
SUPERVISION EXERCISED
: None
ESSENTIAL FUNCTIONS
: Work with/accompany physician at all times Document information in EHR as dictated by provider in exam room Identify and relay information regarding test, procedures, etc. from patient chart Order all labs, imaging, prescriptions, etc. in EHR Retrieve samples Enter diagnoses in EHR Enter charges in MD chart when applicable Complete medical record in EHR for physician to sign Maintain good communication with partnering RMA/CMA Develop strong working relationship with physician Be responsive to provider and patient needs while in exam room Communicate clearly with provider, patient, and co-workers Fulfills organization responsibilities as assigned which may include: respecting/promoting patient rights; responding appropriately to emergency codes; sharing problems relating to patients and/or staff with immediate supervisors quickly. Maintains
OSHA/HIPAA
Compliance as assigned to include: updating manuals; first responder for employees with exposures/incidents. Other responsibilities or duties as assigned. Requirements
EDUCATION
High school diploma, some college preferred. Completed accredited MOA program.
EXPERIENCE
Minimum of one-year work experience in public contact job, preferably service related. CMA/MOA experience in health care or a practice setting.
REQUIREMENTS
Maintain Certified Medical Assistant status through one of the following: American Association of Medical Assistants (CMA) Certification as Registered Medical Assistant with American Medical Technologists. (RMA) National Healthcareer Association (CCMA), National Center for Competency Testing (NCMA) Maintain CPR certification
KNOWLEDGE AND SKILL REQUIREMENTS
Organization skills Excellent, legible penmanship Upper level typing skills — minimum 60+wpm Above average grammar/spelling Knowledge of medical terminology Understanding and compliance with confidentiality/privacy Strong communication skills Familiarity and comfort working within Allscripts — including orders, prescriptions, note, etc. Ability to multi-task Punctuality Ability to focus Ability to cope with job stress Knowledge of health care field and medical specialty. Knowledge of specific assisting tasks related to particular medical specialty. Knowledge of information that must be conveyed to patients and families. Skill intact and diplomacy in interpersonal interactions. Skill in understanding of patient education needs by effectively sharing information with patients and families. Ability to learn and retain information regarding patient care procedures. Ability to project a pleasant and professional image. Ability to plan, prioritize and complete delegated tasks. Ability to demonstrate compassion and caring in dealing with others.
ENVIRONMENTAL/WORKING CONDITIONS
Combination of medical office and exam/procedure room settings. Well-lighted, well ventilated. Exposure to communicable diseases and other conditions common to clinic setting.
PHYSICAL/MENTAL DEMANDS
Must be able to use appropriate body mechanics techniques when making necessary patient transfers and helping patients with walking, dressing, etc. Must be able to lift up to 50 pounds.
