Hospital Transcriptionist

A Hospital Transcriptionist at a medical facility, such as PHYC Hospital, is responsible for accurately transcribing recorded medical reports, patient information, and healthcare documentation. Below is a general job description that outlines the key responsibilities, qualifications, and skills needed for the role:

Job Position: Hospital Transcriptionist

Location: Southern Winds Hospital -PHYC Hospital
Department: Health Information Management / Medical Records
Reports to: Medical Records Manager / Supervisor

Job Overview:

The Hospital Transcriptionist is responsible for transcribing medical reports and records dictated by physicians, surgeons, and other healthcare providers. These reports may include patient histories, examination reports, operative reports, diagnostic results, and other medical documents. The role requires knowledge of medical terminology, excellent listening and typing skills, and familiarity with various transcription software.

Key Responsibilities:
• Transcription of Medical Documents:
• Accurately transcribe dictated medical reports and patient records, ensuring the highest standards of clarity and accuracy.
• Types medical histories, progress notes, discharge summaries, operative reports, and other documentation as needed.
• Maintain patient confidentiality and adhere to HIPAA guidelines.
• Review and Edit Transcriptions:
• Proofread and edit transcriptions for errors in grammar, punctuation, and medical terminology.
• Clarify any unclear dictation with the relevant healthcare provider to ensure correct documentation.
• Medical Terminology Knowledge:
• Utilize knowledge of medical terminology, anatomy, and pharmacology to accurately transcribe complex medical documents.
• Stay updated on current medical practices, medications, and procedures.
• Data Entry and Documentation:
• Enter transcribed documents into the hospital’s Electronic Health Records (EHR) system.
• Organize and maintain accurate patient records, ensuring proper storage and easy retrieval.
• Collaboration with Healthcare Providers:
• Communicate with physicians, nurses, and other medical staff to obtain necessary clarifications or corrections in dictations.
• Ensure that all patient records are completed in a timely manner.
• Confidentiality and Compliance:
• Adhere to all hospital policies regarding patient confidentiality and privacy (HIPAA).
• Follow all hospital guidelines for maintaining secure and accurate records.

Qualifications:
• Education:
• High school diploma or equivalent required.
• Completion of a formal medical transcription program or equivalent certification preferred.
• Associates or Bachelor's degree in Health Information Management or a related field is a plus.
• Experience:
• Prior experience in a medical transcription role or in healthcare documentation is preferred.
• Knowledge of Electronic Health Record (EHR) systems and transcription software is highly desirable.
• Certifications (Preferred):
• Certified Medical Transcriptionist (CMT) or Registered Healthcare Documentation Specialist (RHDS) certification is preferred but not required.

Skills and Abilities:
• Typing Speed and Accuracy:
• Ability to type at a speed of at least 60-80 words per minute with a high level of accuracy.
• Attention to Detail:
• Exceptional attention to detail and ability to ensure accuracy in medical transcription.
• Medical Knowledge:
• Strong knowledge of medical terminology, anatomy, and diagnostic and procedural codes (ICD-10, CPT).
• Communication Skills:
• Excellent written and verbal communication skills for effective interaction with medical staff and physicians.
• Confidentiality:
• Strong understanding of confidentiality laws and regulations, particularly HIPAA.

Physical Requirements:
• Ability to sit for extended periods of time while transcribing.
• Must be able to work in a fast-paced environment and handle multiple tasks simultaneously.

Working Conditions:
• Full-time position with typical office hours, though flexibility in hours may be required depending on departmental needs.
• Work may be performed in an office or remote setting (depending on hospital policies).

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