General Summary:

A non-exempt position responsible for transcribing dictated recordings or live sessions made by physicians and other health care professionals into medical reports, correspondence, and other administrative material, which typically become part of patients’ permanent files.

Essential Job Responsibilities:

Follows providers into patient rooms and listens to physician dictate the encounter aloud.

Transcribes physician statements into a personal computer/EHR.

Edits as necessary for grammar and clarity.

Produces a variety of documents, including discharge summaries, history and physical examination reports, operative reports, consultation reports, diagnostic imaging studies, progress notes, and referral letters.

Returns transcribed documents to the physicians or other health care professionals for review and signature or correction.

Other duties as assigned.

Skills / Abilities:

Knowledge of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments.

Knowledge of how to translate medical jargon and abbreviations into their expanded forms using electronic and printed medical reference materials.

Knowledge of medical record protocols and legal and ethical requirements related to keeping patient information confidential.

Skill in spotting mistakes or inconsistencies in a medical report and checking to correct the information.

Skill in following medical record style standards.

Skill in staying current with medical field changes.

Accurate and moderately fast typing skills necessary.
Ability to understand and question patient assessment and treatment notes to reduce the chance of patients receiving ineffective or even harmful treatments. Ensures high-quality care.

Ability to stay current with medical transcription equipment as the technology changes through ongoing research and education.

Ability to communicate effectively with physicians and other health care professionals related to transcription questions and concerns.

Skill using computer and EMR software.

Education:

High school diploma & Associate’s degree or one-year certificate (certified medical transcriptionist [CMT]) program is recommended, but not always required. On-the-job training often available.

Experience:

Medical transcription experience is preferred, preferably in a medical practice environment.

Work Environment:

Private practice.

Mental/Physical Requirements:

Ability to stand for up to 4 hours at a time while following physician.

Benefits:

• Dental insurance
• Flexible schedule
• Health insurance
• Health savings account
• Paid time off
• Paid training
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday