A Scribe is a medical language specialist who transcribes and interprets dictation by physicians and other healthcare providers in order to document patient care. The position is also routinely involved in research of questions and in the education of others involved with patient care documentation. He/she edits as necessary and returns reports in either printed or electronic form to the dictator for review and signature, or correction.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Transcribe dictated reports and translate medical jargon and abbreviations into their expanded forms.
Identify mistakes in reports, and check with doctors to obtain the correct information.
Perform data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
Produce medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
Return dictated reports in printed or electronic form for physicians' review, signature, and corrections, and for inclusion in patients' medical records.
Review and edit transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology.
Take dictation using either shorthand or a stenotype machine, or using headsets and transcribing machines; then convert dictated materials or rough notes to written form.
Transcribe dictation for a variety of medical reports such as patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation, and/or discharge summaries.
Perform a variety of clerical and office tasks, such as handling incoming and outgoing mail, completing and submitting insurance claims, typing, filing, and operating office machines.
Set up and maintain medical files and databases, including records such as procedure reports, medical histories, diagnostic workups, admission and discharge summaries, and clinical resumes.
Maintains attendance according to scheduled days and hours and appropriate dress and appearance and standards, according to company policy.
Attends mandatory company training sessions as required by state/federal law where applicable.
Seasoned knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values. In-depth or broad knowledge of a specialty (or specialties) as appropriate.
Knowledge of medical transcription guidelines and practices.
Excellent skills in English usage, grammar, punctuation, and style.
Ability to use an extensive array of professional reference materials.
Ability to operate word processing equipment, dictation and transcription equipment, and other equipment as specified, and to troubleshoot as necessary.
Ability to work independently with minimal or no supervision.
Ability to work under pressure with time constraints.
Ability to concentrate.
Excellent listening skills.
Excellent eye, hand, and auditory coordination.
Proven business skills (scheduling work, purchasing, client relations, and billing).
Ability to understand and apply relevant legal concepts (e.g., confidentiality).
EDUCATION AND/OR EXPERIENCE:
Previous experience working in transcription, preferably within Urology.
Excellent overall knowledge of medical terminology.
Job Description Clause
The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of the employer.