Medical Scribe-Health Information Management

Job DescriptionAccompany physicians during patient visits to document real-time interactions and medical information directly into electronic health records.Prepare and assemble medical record documentation and charts for the physician before and after patient encounters.Accurately transcribe patient histories, physical examinations, procedures, lab results, and physician observations as dictated during the visit.Ensure transcription of all medical reports such as discharge summaries, operative reports, cardiology reports, electroencephalogram (EEG) reports, pathology reports, medical evaluations, history and physical reports, consultation notes, progress notes, and other medico‑legal documents in an accurate and timely manner to document patient care.Apply 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.Translate dictated medical slang and abbreviations into their expanded form to ensure the accuracy of patient and health‑care facility records.Clarify dictated information that is unclear or incomplete, utilizing the electronic medical record to confirm laboratory and radiology results, diagnoses, and medication dosages, and seek assistance from physicians, nursing units, offices, and/or ancillary departments as necessary.Submit all transcribed reports to the physician responsible for review, signature, correction, approval and insertion into the patient medical record.Operate word‑processing equipment, dictation and transcription equipment and other specified equipment, troubleshooting as necessary.Ensure accuracy of the header and footer and the correctness of the body of the transcribed material.Ensure correct spelling of medical terms, correct punctuation, and grammar.Ensure proper identification of patient name and medical record number.Identify, interpret and evaluate inconsistencies, discrepancies and inaccuracies in medical dictation; appropriately edit, revise and clarify them without altering the meaning of the dictation or changing the originator's style.Recognize and report unusual circumstances and/or information with possible risk factors to line manager.Recognize and report problems, errors and discrepancies in dictation and patient records to appropriate channels.Verify patient information for accuracy and completeness utilizing the electronic medical record.Identify and eliminate duplicate records both paper and electronic in the dictation system.Stay current with clinical terminologies through publications, seminars, continuing education programs and other changes in the medical industry.Ensure that transcribed document is consistent with all recognized standards.Record productivity and ensure quality monitoring daily; keep accurate work logs and editing sheets and ensure the electronic record of dictations is kept accurate.Respond to verbal and written inquiries in a timely manner.Provide technical expertise in identifying potential issues.Participate in all team efforts as required.Collaborate with other members of the team to carry out work smoothly.AccountabilitiesEnsure completeness, accuracy, and timeliness of all medical documentation and patient records.Maintain compliance with hospital, clinic, and legal regulations, including HIPAA, DOH, and other accreditation standards.Support efficient clinic workflow and provider productivity by reducing the administrative burden on clinicians.Ensure all documentation is reviewed and authenticated by the physician.Maintain a high standard of professionalism, discretion, and patient privacy at all times.ResponsibilitiesProficiency in EHR systems and medical recording software.Strong knowledge of medical terminology, diagnoses, and procedures.Fast and accurate typing skills (typically 60–80 words per minute).Excellent written and verbal communication skills.Strong organizational, multi‑tasking, and time‑management abilities.Ability to work in high‑pressure, fast‑paced clinical environments.Good interpersonal skills for working alongside providers and interacting with patients.High attention to detail and accuracy in documentation.Adaptability to different providers, specialties, and clinical settings.QualificationsEducation, Certifications, and Professional Experience (Required for satisfactory performance on the job):Required: Bachelor’s in health information management or relevant field or Diploma with 3 years of experience.Desired: Additional experience; Bachelor’s degree in a related field.Specialist Certifications: N.A.Desired Certifications: Certification as a Certified Medical Transcriptionist, or equivalent.Experience: 2–4 years of medical transcription experience in an acute care hospita